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pe"S�vACC`5 <br /> STATE OF CALIFORNIA •.,r �o <br /> STATE WATER RESOURCES CONTROL BOARD 3 ` o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMAS ;, atD <br /> • CSI IspKµdr <br /> COMPLETE THIS FORM FOR EAC FACILITYr*rTE <br /> MARK ONLY D NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT & TEMPORARY SITE CLOSURE Cly <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NOF OPERATOR <br /> NEARE�yGRD$S STREET CEL N(OPTIONAL) <br /> A D S' _ / flip/,h/{Let_ <br /> CITY M� STA�A ZIP C S PHO E�1 WI REA CODE <br /> Zoo/ — <br /> v <br /> %.o —✓ BOX -AGENCYORPORATION 0 INDIVIDUAL [] PARTNERSHIP �LOCAL-AGENCY � COUNTY-AGENCY I� STATE OFEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> ,/ IF INDIAN #OF TANS T SITE E.P.A. L D.*(optional) <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME SLAST,FIRST) <br /> PHONE u WITH AREA CODE DAYS: NAME{LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Ir WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION• MUST BE COMPLE71C;ARE <br /> OF ADDRESS INFORMATION <br /> NAME <br /> MAILI=ORSTREET ADDRESS box to indicate 0 INDIVIDUAL [] LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION [] PARTNERSHIP ] COUNTY-AGENCY Q FEDERAL-AGENCY <br /> E ZIP CODE P4 ONE x WITH AREA CODE <br /> CITY NAME <br /> ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> Y <br /> + G R OF ADD E55 INFORMATION <br /> NAM F NER <br /> // Gam. �t✓�Gj 1` f WSJ 611 <br /> MAILINGORSTREETADDRESS ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> L 0 1n X 0 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> S ATE ODE / PHONEi WITH AAj� � <br /> ler <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Call(916)739.2582 if questions arise. <br /> , � •- ��-"moi <br /> _TY(TK) HQ 4 4 -,Q � � G[ '� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I of ll is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> Ik.❑ NI. <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED d.SIGNATURE) <br /> APPLICANTS TITLE DATE MONTH DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# �� JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONA SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGtINFORMATION,ONLY,F =A-R2 <br /> FORMA(9-90) <br />