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-� QeouR es <br /> STATE OF CALIFORNIA 40 <br /> STATE WATER RESOURCES CONTROL BOARD ;� = <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � <br /> 1C�[FORN.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREJIT CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> l vo ecce CA Q�336 '209-" <br /> TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS j� GAS STATION = 2 DISTRIBUTOR IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RES✓ERVATION <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 /> +�- P ' IJ!z 207-2 3 "/z <br /> NIGHTS: 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 F ADDRESS INFORMATION <br /> Gas tre l/r.�� <br /> MAILING OR STREET ADDRESS e ✓ boxt Indicate 0 INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> Aq`fOr CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAM�E� STATE ZIP CODE PHONE#WITH AREA CODE <br /> Z-090_ <br /> -D 2—3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> J_A11110 S <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> INDIVIDUAL OLOCAL-AGENCY 0STATE-AGENCY <br /> Q 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) HQ F4-T-4]- Q Z <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II ischecked. <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,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> YT Cm I I I s�Q �i <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> /�j <br /> - 3 ZSR 3� al 7 <br /> :3. <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) FOR0033A-R2 <br />