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• -ey VR [9 <br /> STATE OF CALIFORNIA • �`; <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� vo <br /> P � 0 <br /> G COMPLETE THIS FORM FOR EACH FACILITYISITE c"��"�"",- <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT [;�4 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET <br /> PARCEL#(OPTIONAQ <br /> Z-7550lc� 1� 95Zo �s � /Hl <br /> CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> TOINDIC TE CORPORATION O INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 0 2 DISTRIBUTOR I 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.%(aplknap <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (24.11 <br /> Z <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME -1-1 <br /> CARE OF ADDRESS INFORMATION <br /> 1- 5 <br /> MAILING OR STREET ADDRESS ✓bubindbale E::] INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> 300-2 =CORPORATION O PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STAT ZIPCO*7 <br /> PHONE#WITH AREA CODE <br /> 4id-.l.�v c �tJ <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,D.Avt i4ldd ?'R <br /> MAILING OR STREET ADDRESS ✓ wxbindbale INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> -27007— QLYy��C( K`(J�Q O CORPORATION Q PARTNERSHIP (] COUNTY AGENCY ll FEDERAL-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> uis/r-n/ uef� t 3 z3 <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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDTO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUM1­.-Y# JURISDICTION# FACILITY# <br /> D 10 Sako z3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> d 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 /> FORM A(490) FOR0033A R2 <br /> a <br />