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Eau <br /> STATE OFCALIFORNIA c�^ <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ? o; <br /> COMPLETE THIS FORM FOR EAC ACILITYfSITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT Evs CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE© <br /> ONE ITEM F-12 INTERIM PERMIT Q 0 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE ' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D <br /> BAOR ,L OM r �/ NA OPE T R <br /> JN G n NEARE CROS$$TRIEET PMCELM(OPrpNA4 <br /> D <br /> CITY NAME / _ STATE ZIP CODR.,x 5Z::o ' SI12 <br /> TE PHONE# I�AREA CDE � <br /> -,{vhyYa l CA L/1 7 <br /> T I/ BOX CORPORATION INDIVIDUAL ] PARTNERSHIP I] DISTRICTS <br /> LOCAL-AGENCY COUNTY-AGENCY ] STATE-AGENCY Ej FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O RESERVATTION #OF TANISB AT SITE E.P.A. I.D.a(oplimel) <br /> O 3 FARM O 4 PROCESSOR O S OTHER OR TRUST LANDS /l//V7 <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 /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box o1rdeate [-IINDIVIDUALI] LOCAL-AGENCY 7-1STATE-AGENCY <br /> CORPORATION f] PARTNERSHIP ]COUNTY-AGENCY I] FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> OF WN C RE OF ADDRESS IN ORMATI <br /> �io�a E17VIf_G)1MP/!l�itQ �h eery ce <br /> MAI NGORS R ETDSD/ itlkLOCAL ED STAVE-AGENCY <br /> ]CORPORATION ] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY V <br /> CI '^AWE STA ZIP CO PHONE II WITH ACO E /y <br /> tri <br /> IV. BOARD OF EQ ALIZA�TION�UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY <br /> JL 7 <br /> TY(TK) HQ 4 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 checke <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.0 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 B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# �/1 - <br /> N�anl <br /> LOCATION CODE NAL CENSUS TWTI -FNAL 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.FOROMM Rz <br /> FORM A(9-90) <br />