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r oa s <br /> STATE OF CALIFORNIA c <br /> STATE WATER RESOURCES CONTROL BOARD 3y_ ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� ue <br /> >,,.. o <br /> �41sOn NDN <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 t NEW PERMIT F--j 3 RENEWAL PERMIT E 6 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME V <br /> 0 ^ NAME OF OPERATOR <br /> ADDRESS irk^ b I �� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME S STATEZIP CODE SITE PHONE*WITH AREA CODE <br /> CA <br /> T NOBox CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY I� STATE-AGENCYFEDERAL-AGENCYDISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.0.*(optional) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR O 6 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 /> 71 <br /> II. PROPERTY OWNER INFORMATION. MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL Q LOCAL.AGENCY STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP Q 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 box bbdkele INDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> O CORPORATION PARTNERSHIP COUNTY-AGENCY 0 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—[-4]-� <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: L a 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 /> APPLICANPS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al FACILITY# <br /> UNOC�zf� 4.,094Z' <br /> LOCATION OOD�OPTIONAL CENSU$TR&CT* --QPTIONAL SUPVISOR�STRI'T CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AAT LSLEEASTT((1))OR <br /> RR MORE PERMR APPLICATION- FORM BB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> F0ROMIA RI <br /> FORMA(9-90) <br />