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�youR es <br /> STATE OF CALIFORNIA P '"`•"• CG <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A4: <br /> d <br /> • i <br /> COMPLETE THIS FORM FOR EACH ACILITYISITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE RZE1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME /' NAME OF OPERATOR <br /> JZ r —4. <br /> ADDRESS It NEAREST CROSS STREET PARCEL#(OPTIONAL <br /> z s cs <br /> CITY N ME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ken G CA <br /> TO NDIICCATE D CORPORATION INDIVIDUAL Q PARTNERSHIP L__j LOCAL-AGENCY I7 COUNTY-AGENCY STATE-AGENCY [] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NkGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S I c ICS <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY CI STATE-AGENCY <br /> CORPORATION PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 4 f4l- <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked, <br /> CHECK ONE BOX INDICATING WFI CH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND B[LLING: I.7] II. III.0 <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE GATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> GODU TYNT.+Y�I# JURISDICTION# FACILITY# <br /> LOCATIONN}CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR•DISTRICT WOE -OPTIONAL <br /> [ 1r ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S-SO) FOR0033A-112 <br />