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�youRCPs <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A r4 _ aid <br /> ti <br /> COMPLETE THIS FORM FOR EACH WILITYISITE <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> I <br /> ADDRESS 1 NEAR ST CROSS STREET PARCEL#(OPTIONAL) <br /> I ( o <br /> CITY NAME STATE ZIP COD SITE PHONE N WITH AREA CODE <br /> CA <br /> TO DIICCATE 0 CORPORATION ®INDIVIDUAL I= PARTNERSHIP ® LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.N <br /> RESERVATION 1QAfiona!) <br /> 3 FARM d PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING O STREET A ] ✓ box b kale [] INDIVIDUAL [] LOCAL-AGENCY 0 STATE-AGENCY <br /> DDRD , 1 ,;' a RMRATION PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME S E� ZIP DE PHONE N WITH AREA CODE <br /> tJ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING RSTREET ADD RESS ✓ box bIndicate <br /> E71 INDIVIDUAL LOCAGAGENCY STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY E71 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4T4 - <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: X. Ik.LA II. <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 MONTFIIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 131 Dvv <br /> LOCATION CODE -OPTIONAL CENSUS TRACT N -CIPrlON L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Q A3 <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 /> F FIM A(9-901 FOROG�3A-R2 <br /> :l <br />