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eco�n ey <br /> STATE OF CALIFORNIA • ^ee ' " o <br /> STATE WATER RESOURCES CONTROL BOARD g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W n� ° <br /> c � . <br /> COMPLETE THIS FORM FOR FACILRYISRE °�x,.o°�,� <br /> MARK ONLY Q I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT � 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE CI](,-(�/( <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACT IF NAM ^/ .L- NAMEOFOPERATOR <br /> ADDRESS I IJ/ <br /> 3515AWij DrIve, 7 NEAREST CROSS STREET PARCEL#(OPFN)NAp <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> "I BOX <br /> TOINDIIC TE O CORPORATION 0 INDIVIDUAL =PARTNERSHIP 0 LOCAL AGENCY 0 COUMYAGENCY 0 STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 3 GAS STATION 0 2 DISTRIBUTOR q SERVINIAN ATION #OF TAN AT SITE E.P.A. I.D.#(optwnai) <br /> 3 FARM Q 4 PROCESSOR � 5 OTHER OR TRUST LANDS Z <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 /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindka Il INDIVIDUAL E::] LOCAL-AGENCYSTATE-AGENCY <br /> ED CORPORATION = PARTNERSHIP COUNTY-AGEWY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box birKIR e D INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION O 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 4 4 -L_L I I —F]—] <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: 1.0 II.E III.❑ <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# jJ07"f JURISDICTION IF FACILITY# <br /> ® 5ToeK 03 1 / 17-1 l D wol 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR- ISTRICT CODE -OPTIONAL <br /> p/ 25. 15 32 <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 />