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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD c <br /> NDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISrrE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT E;wj�CHANGE OF INFORMATION O 7 PERMANENTLY CLOS <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE b� <br /> I. CILITYISITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> ORFLITY NAME ^ NAMEOFOPERA R <br /> ADDRESS <br /> 70O p 5 <br /> Q NEAREST CROSS S EET PARCELA(OPTIONAL) <br /> 2C <br /> CITY NAME STATE ZIP CODE TE PHONE#WITH AREA COD <br /> La ��rm CA 53 zdI SA'7-5-3 Z <br /> V BOX <br /> TO INDICATE O CORPORATION ( I INDIVIDUAL 0 PARTNERSHIP Q-LpCpppGENCY 0 COUNTY-AGENCY STATE-AGENCY <br /> DSTRICTS O fEDEPALA EN <br /> CV <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#TapAmal) <br /> O 0 ATION <br /> OR TRUSTESEVLANDS <br /> —7 - <br /> 3 FARM 4 PROCESSOR OTHER <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME ILA ST FIRST) PHONE#WITHAREA CODE DAYS: NAME(LAST,FIRST) PHONE WITH AREA COD <br /> 05 o C)q - 7 S <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA COD <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR ST TADORESS - ✓ box b indicate =1 INDIVIDUAL AL-AGENCY 0 STATER NCY <br /> O 3 _. Ej CORPORATION 0 PARTNERSHIP COUNTYAGENCV = FEDERAL GENGY <br /> CITY NAME a/ STATEE9 ZIP CODE Z 6 ZEE#WITH AREA CODE <br /> an ec J 9 �rZ53z z_ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate D INDIVIDUAL 0 LOCAL-AGENCY STATE.AGCY <br /> O CORPORATION = PARTNERSHIP = COUNTY-AGENCY FEDERAL GENCY <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) HQ [4 F4 - <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. III.5:1- <br /> TMS <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 a SIGNATURE) APPLICANTSTITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISD�ICTIOON# FACILITY# S C IMA-flTE2 <br /> LOCATION CODE -OPTIONALTRACT-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> r CENSUS 2 3 w 3U" <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. <br /> FORM A(9-90) F R0033AR2 <br />