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STATE OF CALIFORNIA 11110 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE <br /> MARK ONLY F__j 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO RE <br /> ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE' .53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI E NAMEOFOPERATOR <br /> ADDRE S NEARE TCROSSS PARCEL*(OPTIONAL) <br /> O <br /> CIN NAME ^ STATE IP CODE SITE PHONE;1 WITH AREA CODE <br /> JCA <br /> ✓ Wx ORPORATION [� INDIVIDUAL 0 PARTNERSHIP D LOCAL-AGENCY D COUNTY-AGENCY O STATE-AGENCY D FEDERAL-AGENCY <br /> TO INDICATE <br /> DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN If OF TANKS AT SITE E.P.A. I.D.#(apbmap <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTA PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) HONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM / !' ^ J CARE OF ADDRESS INFORMATION <br /> MAILING TREETADD S `I{—w [/ ✓ box blMicam 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION D PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAT —STATE ZIP CODE PHONE*WITH AREA CODE <br /> C `4 /S 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa binkala INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. III.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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Lwow S <br /> 1J L) <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> - 3, . <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 /> FOROMM R2 <br /> FORM A(9-90) \ <br /> C("� iE <br /> / \ <br /> DATA PROCESSING COPY <br />