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STATEOFCAUFORWA <br /> • STATE WATER RESOURCES CONTROL BOARD <br /> cfiv4 <ti UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y a <br /> o" <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ARK ONLY tj 3 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> E ITEM 2 INTERIM PERMIT Q T PERMANENTLY CLOSED SITEQ d AMENDED PERMIT g TEMPORARY SITE CLOSURE <br /> 1 9 9 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAMEOFOPERATOR <br /> ADDRE.g� <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> E . <br /> CITY NAME <br /> ✓ BOX <br /> C 10x6 7� STATE ZIP CODE SITE PHONE s WITH3(a CODE <br /> TO INDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNN-AGENCY STATE-AGENCY 06TPJCTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR ✓ FR INDIAN NOF TANKS AT SITE E.P.A I.D.#(aptiuul) <br /> O 3 FARM Q d PROCESSOR l i OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlongl <br /> DAYS: NAME(LAST,FIRST) a LM� PHONE N W AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIC T$:'NgME(L n/✓Vrr. PHONE N WWII,T,H AREA CODE J NIGHTS: NAME(LAST,FIgSn PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME n CARE OF ADDRESS INFORMATION <br /> I -A,' ti L(Jv j <br /> MAILING OR STREET ADDRESS ✓ hm bintlkale INDIVIDUAL <br /> O LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME E:I CORPORATION Q PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED OWNER CARE OF ADDRESS INFORMATION <br /> sr� l --To O r N c .� -ie PQoL <br /> MAILING OR S1 REEI ADDRESS ..'mX2% 0 INDIVIDUAL <br /> P c'' AD (gro 0-canv/Z /IDOL OLOCAL-AGENCY O STATE AGENCY <br /> CITY NAME (�CORPORATIONO PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> y� lj� / STG ZIPS ,^ PrONE#WIT 9REA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> Y- 3ff7 <br /> TY(TK) HQ F4-[-4]-L <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 /> I.E::] II.=1 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN.Y# JURISDICTION# FACILITY# <br /> LOCATION CODE-OPTIONAL CgWSULSTRACTI-OPTIONAL SUPVISOR-DISTRICT CGDE -OPT/ONAL <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(9.90) FOR0W3A-R2 <br />