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• • oua e <br /> STATE OFCAUFORNIA e i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> H> . <br /> COMPLETE THIS FORM FOR EAT FACILITYBITE <br /> MARK ONLY 71 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT E] 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE Oil <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAMEOFOPERATOR <br /> N)'-I <br /> ADDRESS ��� /&(-k�T�� 4, NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME O-W-Y17 STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> fi�k�o,✓ CA 95.20G <br /> TO INDICATE D CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY <br /> OSTRICTS <br /> TYPE OF BUSINESS O t DAB STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.♦tepNmap <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR O 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 a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a 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 /> MAILING OR STREET ADDRESS ✓ boab Wicale E:1 INDIVIDUAL E3 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY El FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE;r 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 0 Mica D INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION a PARTNERSHIP O COUNTY#GENCY FEDEML-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(918)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> = AWXIS' <br /> LOCATION DE -OPTIONAL CENSUS TRACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2 3. S Z \ <br /> U <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(9-90) FOROMA R2 l` <br />