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• STATE OF CALIFORNIA • . ..... <br /> STATE WATER RESOURCES CONTROL BOARD cto <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT Dg 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / <br /> Ce OR FACILITY NAME NAME OF OPERATOR <br /> Ce <br /> C I L <br /> ADDRESS NEAAe-ES-TCROSS STREET PARCEL#(OWIONAq <br /> q2 IJ . g*' - <br /> 23o-oq <br /> CITU NAME STATE ZIP CODE <br /> I�iT�cku9iA CA 95 20 je PHONE#WITH AREA DE <br /> TOINDCATE D CORPORATION l� INDIVIDUAL PARTNERSHIP D LOCA4AGENCY y r/O_ <br /> d6TRICTS 0 COUMY-AGENCY � STATE-AGENCY 0 FEDERALAGENCY <br /> A TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TA�AT SITE E.P.A- I.D.#(oplinnAl) <br /> Q 3 FARM O 4 PROCESSOR ,may 5 OTHER O RESERVATION <br /> 40 IO' OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREACODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM C E OF ADDRESS INFORMATION <br /> IA u � ` � t3�Dw as <br /> MAILING OR STREET ADDRESS ✓ 6oa blMbaur <br /> `J� O LOCAL AGENCY l� STATE AGENCY <br /> E Q CORPORATION PARTNERSHIP COUNTY Q FEDERALAGENCY <br /> CITU NAME ST ZIP CODE <br /> ^G�� PONE ITH AREA CODE <br /> III. TANK OWNER INFORMATION. MUST BE COMPLETED) J <br /> NAM OF OWNER <br /> CAREFADD�RESS INFORMATION b <br /> MAILING OR STREET ADDRESS tteefhmbbtlb -��C^OW <br /> m2sii E�] INDIVIDUAL Q LOCAL-AGENCY AGENCY = <br /> CITY NAME L.. D CORPORATION 'PARTNERSHIP 0 COUNTY-AGENCY 0 FEDEMLdGENCY <br /> STA ZIP CODE P ONE# ITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-F4]-� <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: I. <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 MONTH/DAVNFgq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCA NCOOE -OPTOONAL NSUS TRACTI -OPTIONAL SUPVISOR-OISTRIC7 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 /> FORM A(9.90) <br /> FOR9pgOAA2 <br /> m <br />