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0 oua ea <br /> STATE OF CALIFORNIA � �`^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PE=APATION- FORM A .� sCOMPLETE THIS FORM FOR Ee�x�.°"��° <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT CYS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE-71 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> V uc of o f � .__ To�nsan <br /> ADDRESS I NEAREST CRO STREtT PARCEL IOFTIONAu <br /> L-e' <br /> CITY NAME ••,n7 AA STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> {'Vt R vl CAS CAI/ BOX <br /> �7�y <br /> TO INDICATE D COR ATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY E--] COUNTY-AGENCY D STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS T GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NA E( .FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box min&.I. = INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> d 727 40, I-A-)V O CORPORATION = PARTNERSHIP = COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME SPe� STATE ZInP ;; 3 PHONE I WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) WW !o <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> -vkGl w /TS 'X— <br /> MAILING <br /> MAILING OR STREET ADDRESS ✓ box bintlkals 0 INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY <br /> Q CORPORATION = PARTNERSHIP (] COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITHAREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - p <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. 111.❑ <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 TIRE DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> c 3 ro <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) Io- � FOR009A-R2 <br /> 6 v All 2 A <br />