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• • oo. ea <br /> STATE OF CALIFORNIA ,,.• °s <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A va <br /> D <br /> G <br /> COMPLETE THIS FORM FOR E!EH FACILfTYBRE °•�,•o.w• <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ,SQ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME OF OPERATOR <br /> Tn7d fr 1W— <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5--Ack4ap) CA 9szo3— <br /> TOIN Box O CORPORATION �INDIVIDUAL O PARTNERSHIP 0 LOCAL-DISTRIAGENCY 0 COUNrY-AGENCY I� STATE-AGENCY I� FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR ❑ RESEIF INDIAN RVATION IN OF TANKS AT SITE I E.P.A. L D.#(opikaW) <br /> Q 3 FARM a d 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bobintlkau D INDIVIDUAL Q LOCAL-AGENCY E3 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE 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 ✓ bm ID WICKS Q INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> (]CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY Q 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-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.[—] II.❑ IN. <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) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> z3 / T�bvY37 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL Sl1PVISOR-DISTRICT CODE -OPTIONAL <br /> 23.2-3 3 i S— / Mfl c <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) FOR0073A-R2 <br />