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u _ <br /> `\O pt50UP f9 <br /> l` V STATE OFCAUFORNIA <br /> C/ STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND <br /> STORAGE TANK PERMIT APPLICATION- FORM A ve <br /> W�fpy \ COMPLETE THIS FORM FOR EACH F ILITYISITE <br /> MAflK ONLY NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLO E <br /> ONE ITEM 72 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME 1 NAME OF OPERATOR <br /> I <br /> STREET PCEL%(OPIADDR N R STCROSS NAL) <br /> 3507 S -§OYL <br /> 09.2- 1 0-1a- 3 <br /> CITY NAME STA77 <br /> CA az) 57 A <br /> ZIP DE Q 51 PHONE%WITHACODE�?W <br /> I/ BO% <br /> TO INDICATE CORPORATION O INDIVIDUAL O PARTNERSHIP DISTRICTS <br /> �CY COUNTY-AGENCY STATE-AGENCY [71FEDERAEPAL-AGENCY <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR -OR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.0.#(optional) <br /> ,L(�Q/ RESERVATION 1 <br /> 3 FARM 0 4 PROCESSOR 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS' NAME(LAST,FIRST PHO #WIT Fj EA D DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a (L3 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH REA CODE NIGHTS: NAME(LAST.FIRST) PHONE%WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> iliaa, <br /> MAILING OR STREETAODRESS ✓ box bindkare INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> 'a S t Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME C Sj[�TE ZIP DE A PHONE%WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) `TJ' <br /> NAME OF 9VYNER CARE OF ADDRESS INFORMATION <br /> MAILIN ORS R ET ADDRESS c box bindk" C2 14DUAL O LOCAL-AGENCY STATE-AGENCY <br /> El CORPORATION 0 PARTNERSHIP =COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NA E ^ STATE ZIP CODE O PHONE#WITH AREA CODE <br /> IV. BOARD OFF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBBEFRR--Call(916)739-2582 if questions arise. <br /> TY(TK) HQ4 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 ghecked, <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> al <br /> D S �FlII'T 35 <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT% - TIONAL BUPVISOR-DIBTRICT CGDE-OPTIONAL <br /> a3 • 3A -5-9i <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 /> FOR0033A R2 <br /> FORMA <br />