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• STATE OF CALIFORNIA • ecooAc�y <br /> STATE WATER RESOURCES CONTROL BOARD • c'9 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> s , o <br /> COMPLETE THIS FORM FOR EACH F YISRE n `"•J^"' <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ <br /> ONE ITEM ❑ 7 PERMANENTLY CLOSED SITE INTERIM PERMIT <br /> ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FA INFORMATI &ADDRESS- PLETED) <br /> D OR FACILITY NAME <br /> E OF <br /> c <br /> .7(� T CRS�^^^^ PARCEL#OPTIONA <br /> S' uin PIU✓ <br /> CITY NAME STATE ZIP CODE <br /> 3 SITE PHONE#WITH AREA CODE <br /> d <br /> ✓ BOX ` '' CA. C�SaU — A[�O — ?�0 <br /> TOINDICATE OflPC) ATION 0 INDIVIDUAL 0 PARTNEflSNIP 0 LOCAL-AGENCY <br /> DISTRICTS <br /> 0 COUNTY-AGENCY 0 STATE-AGENCY I� FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.1: A. I.D.#(aprim#q <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON EMERGENCY CONTACT PERSON SECONDAR <br /> DAYS: NAME(LAST,FIRSn' PHO x WIT AREA CODE ( YI'OPIIOneI <br /> DAYS: NA (LAST,FIRSn PHONE#WITH AREA CODE <br /> e-I h q rf 73 73 �3/3 <br /> NIGHTS: NAME( T,FIRSn E#WITH AREA CODE NIGH � E(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME �- CAREOF ADDRESS FORMATION <br /> u <br /> MAILING OR STREET ADDRESS ✓ box I�te <br /> 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME E7 li sh r^ y-iJ79 (/ RPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> /y C4 9moa <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bAgkab <br /> O INDIVIDUAL 0 LOCAL 5TGY 0 STATE AGENCY <br /> CITU NAME 0 CORPORATION ED PARTNERSHIP O COu1RY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE x WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 14:141- <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1. ILO IT.O <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 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/OAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# I U 7/ <br /> LOCATION CODE -OPTIONAL CENSUS TRACTi -OPT/ONAC SUPVISOq-DISTRICT CODE - <br /> OPTIONAL <br /> a3 <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(9.90) <br /> FORR00^333A 82 <br />