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Daces <br /> STATE OF CADFJpNIA `O <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F 2 INTERIM PERMIT 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME p NAME OF OPERATOR <br /> : vn to NSD/1�O5�r/1 Ire <br /> ADDRESS NEARESTCROSSSTREET PARCEL#(OPTIONAL) <br /> 1793`/ r. rzU <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> n CA 5566 <br /> TOINDIICCATE -1 CORPORATION D INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY D COUNrY.AGENCY [7]STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O V 'F <br /> IF INDIAN x OF TANKS AT SITE E.P.A. I.D.*(eptlona# <br /> flESERVATION ^^,,...,, <br /> O 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE*WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> on CoslSa , ✓t <br /> MAILING OR STREET ADDRESSt II -- ✓ box bindkate O INDIVIDUAL O LOcAL-AGENCY 0 STATE-AGENCY <br /> 114�Z' E- `4,zZ U f�CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITU NAM STAT ZIP CODE 6 PHONE*WITH AREA CODE <br /> O L/' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box bindlem D INDIVIDUAL LOCAL-AGENCY E-1 STATE-AGENCY <br /> CORPORATION D 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 4 4 - Q 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: 1.0 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION* FACILITRIPON 17 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(& <br /> TO <br /> 3A-R2 <br /> • • ✓ O <br />