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^P♦�'5pru� pp <br /> STATE OF CALIFORNIA - <br /> STATE WATER RESOURCES CONTROL BOARD 3 nom . w 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , a <br /> •p�ll�p�Y� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT F a TEMPORARY SITE CLOSURE <br /> F_ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME - - NAMEOF PERATOR <br /> Px el /q NNUJJ Q PMCEL/IOPTIONAL) <br /> NEAREST CROSS STREET <br /> ADDRESS <br /> Q r C� <br /> CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> h6t&) CA 9sao <br /> i I/ Box <br /> xTE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 3 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN •OF TANKS AT SITE E.P.A. L D.A(apNmel) <br /> Q RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST.FIRST) PHONE A WITH AREA CADS DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE r 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 /> e Rs <br /> MAILING OR STREETADDRESS ✓ box b CORPORATION <br /> 0 INDIVIDUAL 0 LOCAL-AGENCY EN 0 STATE-FEDERAL-AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE WTH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES box biXx=s OINDIVIDUAL E3LOCAL-AGENCYOSTATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE✓r 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 ox I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.pr II-E] III.E <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 /> a = STANTe2`7 2 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 12 3, so 1 -314-5- <br /> THIS <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(9.90) <br />