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R � <br /> %W STATE OF CALIFORNIA tea o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> /UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 P RMANENTLY CLOSED SITE \ <br /> ONE REM 0 2 INTERIM PERMIT EI] 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION Ik ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME / jam/ NAME OF OPE RAT R <br /> ///� <br /> ./� NEAESTCROSS TREETADDRESS / <br /> PARCEL#(OPTIONAL) <br /> 2ra C/ /v-30/Q <br /> CITY NAME STATE PTE PHONE*WITH AREA COD <br /> 4n �erle Ca gz <br /> BOA <br /> TOINDLATE ;•L ``ORATION D INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY O COUNTYAGENCY O STATE-AGENCY O FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION <br /> IF INDIAN <br /> A OF TANKS AT SITE E.P.A. I.D.#(npImnel) <br /> 0 3 FARM O 4 PROCESSOR [;�OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �i S o 2 �Z/6 ll <br /> NIGHTS NE(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (�; 7�5 , 9-1 3-7_/6 S- <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> {i9aIt / 5A__s <br /> MAILING OR STREET ADDRES / b°tulnEbau O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O p /A7t/ S CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERALAGENCV <br /> CITU NAME _.1 n / _ ST�# ZIP 5 3 3 6 PHONE t WITH AREA CODE <br /> IY/ J!'C�, Gq <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER 1 wC 5 CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESSbcl blrMi 0INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> Z� v�(���// �� �RATN)N 0 PARTNERSHIP � COUNTY-AGENCY 0 FEOERALAGENCY <br /> CITY NAME 44 STATE4 ZIP CODEL 3/ I PHOS WITH A�-5 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> -Call(916)739-22582 if questions arise. <br /> CD r <br /> TY(TK) HQ F4-T-41- Z (� <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 11.[::] III.E�t— <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PRINTED B SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# /yov..f/T/Z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA-R2 <br /> FORM A(9-90) <br /> L *m 04 <br />