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ezooe es <br /> STATE OF CALIFORNA <br /> STATE WATER RESOURCES CONTROL BOARDTX a o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> °4mon M•� <br /> COMPLETE THIS FORM FOR EACH FACT VISITE <br /> MARK ONLY O ) NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMA TLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME ( NAME OF OPERATOR <br /> c,��irr ru H 5 <br /> ADDRESS p EAflEST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATEZIP CODE SITE PHONE WITH AREA CODE <br /> S� C� CTM CA �L ZD 9Y6 G& Llk <br /> BOX <br /> TO INDICATE D CORPORATION Q INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY L-I COUNTY-AGENCY O STATE-AGENCY [_1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 i GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.a Wicnal) <br /> 0 3 FARM a PROCESSOR 5 RESERVATION <br /> OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) c. �HONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> e rru.g7q�(o-OIoYS <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMbale 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP Q COUNTY#GENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 b Indicate INDIVIDUAL 0 LOCAL-AGENCY (]STATE AGENCY <br /> 0 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-41-[C) 3 a 6 <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: t.O II.[—] U. <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 57VGk VIV <br /> LOCATION CODE -OPTIONAL CENSUS TRI �� SUPVISOR-DISTDE -OPTIONAL �/G <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 />