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N11 t4a <br /> 0 . P4'69 vM[rF5 w <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FA ITY/SFTE <br /> MARK ONLY `NEW PERMLT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTL <br /> ONE-ITEM 2 INTERIM PERMIT ti 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MS BE COMPLETED) <br /> f <br /> DBA0AFACILITY NAME NAME FOPERATOR <br /> rJ �ti �! <br /> A D ESS NEAR ST CROSS STREET <br /> PARC ELN{OFTK}NAL) <br /> CITY N ME <br /> STATE �ZIP CODE SITE PHONE N WITH AREA CO i <br /> TOINDIICCATE E�]CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS �I 1 GAS STATION = 2 DISTRIBUTOR "' IF INDIAN q OF TANKS AT SITE F.P.A. I.D.4(optimal) <br /> ��I RESERVATION <br /> 3 FARM 4_PROCESS-OR 5 OTHER OR TRUST LANDS <br /> _-EMERGENC—CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE'. DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> L d -- <br /> IG TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 12-Gi - AG <br /> AILING OR STREET ADDRESS ✓ box IDind{tate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION F71PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMET ZIP CODE�� � PHONE W�H AREA CODE <br /> STA <br /> 42 19 LT <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> f <br /> MAILING OR STREET ADDRESS ✓ box b Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 12 Z 17 6 f l [� Q ®CORPORATION 0 PARTNERSHIP [ COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> CT A C 4 1ls 3 6 C acy - <br /> IV.i3OAFID OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 0 7 <br /> `., V, LEGAL NOTIFICATION AND BILLING ADDRESS Legal nolificaligo wd.billing will be-sent to the t�ii downer unless box I or II is checked. <br /> CHECK OEBOXiND4GATIN[�WHICH ABOVE- DDRESS SHOULD BE USED FOR LEGAL N071FICATIONS AND BILLING: I.C II.1-7III.0 <br /> N <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 MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# �'�/✓J/nS / <br /> LOCATION CODE -OPT[ NAL CENSUS TRACT N -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 /> FOR0033A-R2 <br /> FORMA(9-90) /�� <br />