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STATE OF CALIFORNIA • c� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> -UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �a <br /> COMPLETE THIS FORM FOR EACH F LfTY/SRE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE Y CLO SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET PAgCEI Y(OPTIONAL) <br /> CIT'NAME <br /> STATE ZIP CODE SITE PHONE M WITH'AREA CODE <br /> CA %S Zv <br /> TO INDICATE C:I CORPORATION Q INDIVIDUAL Q PARTNERSHP Q LOCAL-AGENCY Q COUNTYAGENCY [j STAIE.AGENCY FEDEPALAGEACY <br /> DISTRICTS <br /> TYPE OF 3USINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INOIAN s OF TANKS AT SITE E.P.p. L D,A I4P4rlal/ <br /> ❑ ATI <br /> O FARM d PROCESSOR 5 OTHER OORp RUSTVLAION <br /> NDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonel <br /> GAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE r WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-JMUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bOl biMbalA <br /> C INDIVIDUAL Q LOCAL AGENCY O STATE-AGENCY <br /> CITU NAME O CORPORATION Q PARTNERSHIP 0 COUNTY#GENCY Q fEOEWLI-AGENCY <br /> STATE I ZIP CODE PHONE R WITH AHEA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE <br /> OR STREET AOORESS OF ADDRHESS INFORMATION <br /> MAILING ✓ OOA b b <br /> Q INDIVIDUAL = LOCAUAGENC� a STATE-AGENCY <br /> CITY NAME CORPORATION Q PARTNERSHIP Q CoumN AGENCY O FEDERAL AGENCY <br /> STATE ZIP CODE I PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 it questions arise. <br /> TY(TK) HQ [474 - <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 SILLNG: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APVUCANTS NAME(PR WTEO A SIGNATURE) APPLICANTS TITLE <br /> DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION x FACILITY p <br /> ' y Y <br /> LOCATIONCOOE -OPTIC,7 L (CENSUS TRAC PT/ONAL ISUPVISOR-DISTRICT COGS -OPTIONAL <br /> 3C� <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(390) <br /> FCN0=A-R2 <br />