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STATE OFCAUFORNIA <br /> C y9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT E2--r—CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Ai/rT' W-v Frh,0-41S <br /> A7V�� C �Z4�/E� n� NEAREST CROSS STREET PAi10ELx(OPrgNAu <br /> CITY NAME L K/l STATE ZIP CODE SITE PHONE x WITH AREA CODE <br /> /kA_-p°o CA X152 2.0 <br /> ✓ SOX <br /> TO INDICATE O CORPORATION DIVIDUAL E=j PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY D STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 I S STATION 0 2 DISTRIBUTOR RESERVATION #OF TANKS AT SITE E.P.A. I.D.4(op!analJ <br /> 3 FARM F7 4 PROCESSOR = 5 OTHER OR TRUST LANDS o <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) �P/HONE x WITH AREA—CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> � I/L� 2IJG <br /> NIGHTS: NAME(LAST,FIRST) PHONE x 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 ✓bwt b Indkale 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION ] PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY <br /> CITU NAME STATE ZIP COO€ PHONE#WITH AREA CODE <br /> G/1 qh Zea <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /h`mc- iD47pv L5 <br /> MAILING OR STREET ADDRESS yy ( p n ✓ box Ioindkale INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> "70-:q O CORPORATION E-1 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> Pv 6 L ZD <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O 11.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP L ICANTS NAME(PH INTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ! lfi6tfrTic/ 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL r--T— I ` Z q Z, <br /> 3 . 2Z 5Z.0 L <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 /> FORMAR2 <br /> FORMA(9-9G) <br />