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ISpJACPg <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> r COMPLETE THIS FORM FOR EACH FACILRYISRE <br /> C_J 0 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY NEW PERMIT <br /> ONE ITEM Q 2 INTERIM PERMIT <br /> 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME ovOPERATOR <br /> DBA OR FACILITY NAME 10/J PARCEL It(OPTIONAL) <br /> P�^ 012- - NEARESTCROSS STREET <br /> ADOflESglal E- <br /> STATE ZIP LADE SITE PHONE s W ITH AREA CODE <br /> CITY NAME CA <br /> Ma COUNTY-AGENCYO STATEdGENCY 0 FEDERAL-AGENCY <br /> I/ BOX ED CORPORATION INDIVIDUAL 0 E3PARTNERSHIP OGTWLOCAL-C SAY O <br /> TOINDCATE ,/ IF INDIAN r OF TANKS AT SITE E.P.A. L D.* WIK^al) <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR C7 RESERVATION <br /> a 0 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE+t WITH AREA CODE <br /> GAYS: NAME(LAST.FIRST) PHONE•WITH AREA CODE <br /> PHONE:I WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> if. PROPERTY OWNER INFORMATION" MUST BE COMPLETED CAR p00R/ESS INFORMATION <br /> NAME N7�h N'vY <br /> CG STAT <br /> ✓ bot W 46CAte Q INDIVIDUAL O LOCAL-AGENCY f�GENCY <br /> MAILINGORS REETADDRESS Q CORPORATION Q PARTNERSHIP Q COUNTYJ,GENCY 0 FEDERAL-AGENCY <br /> o <br /> STATE ZIP CODE PHONE M WITH AREA CODE <br /> CITY NAME s33 <br /> TF!=]Eaj <br /> INFORMATION (MUST CARE OF ADDRESS INFORMATION <br /> /i�j v babim 0 INDIVIDUAL Q LOCALAGENCY Q STATE AGENCY <br /> Q CORPORATION 0 PARTNERSHIP Q COUNTYAGENCY 0 FEDERAL-AGENCY <br /> STATE 21P CAGE PHONE <br /> IV.BOARD OF EQUALIZATION U ^ FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -L�L�I I <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II s c eckO <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,A TRUE AND CORRECT <br /> APPLICANTS TITLE <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY FACILITY p <br /> COUNTY p JURISDICTION <br /> 144,4-AgT g <br /> TRACT;1 -OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> LOCATION CODE -OPTIONAL CENSUS <br /> 23.8 d <br /> FORM B,UN <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION• LESS THIS IS A CHANGE OF SITE INFORMATION ONLY.FOR9933A A2 <br /> FORM A(9-90) <br /> aa'�� <br />