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STATE WATE STATE OF CALIFORNIAR RESOURCES CONTROL BOARD <br /> • ebuua es <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> vo <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE ,�, o <br /> MARK ONLY ❑ ) NEW PERMIT n e"'ep"��e. <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ❑ 4 AMENDED PERMIT ❑ T PERMANENTLY CLOSED S! <br /> ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME <br /> ADDRESS /'JP�!/(�� / NAME OF OPERATOR <br /> CITU NAME �,s NEAREST CROSS,TRE RE PARCEL#(OP ZONAL) <br /> S /�✓ �O <br /> STATE ZIPCgDEBOX <br /> `+A ef- T d TE PHO ��*WITHAR CODE <br /> TO NOICATE �CORPORATION �INOIVIDUpL 0 PARTNERSHIP Z91470CsKawJ <br /> TYPE OF BUSINESS O ) GAS STATION O DSTRICTS�CV 0FUMY-AGENCY Q STATE-AGENCY ED FEDERAL-AGENCY <br /> ❑ 4 DISTRIBUTOR ✓ IF INDIAN I OF TANKS AT SITE E,p,A. D#rte/ N/ <br /> ❑ 3 FARM ❑ 4 PROCESSOR OTHER ❑ RESERVATION <br /> OR TRU37 LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> F(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY PHONE# ITH AREACODE ) Optlnel <br /> DAYS: NAME(LAST,FIRST)E(LASTFIRST) PHONE A WITH AREA CODE <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE I WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> Z J 4�v6,J _-re �/�/ � ✓boc b inCicale <br /> 4 - INDIVIDQ UAL OCA4AOENCY <br /> CITY,NAME 0 CORPORATION 0 PARTNERSHIP 0 C 0 STATE-AGENCY <br /> OUNTYAGENCV <br /> STATE ZIP CODE F7 FEOEgALAGENCY <br /> PHONE I WITH AREA CODE <br /> ZZU <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER / <br /> CAREOFADDRESS INFORMATION <br /> AILING OR STREET ADDRESS <br /> fC. _t .rr� box biMXap <br /> CITY ME me /I " T O CORPORATION 0 PARTNERSHIP O SAL-PO�CV STATE-AGENCY <br /> ZIP CODE <br /> STATE �COUNTY-AGENCY Q FEDERALAIV- GENCY <br /> PHONE#WITH <br /> TYY(TK) HQ 4 4 AgEA CODE <br /> BOARD OF EQUALIZATION¢ATIO"U� FEE ACCOUNT NUMBER-Call(916) 73�82 if questions arise. <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 ABOVEADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE,IS TO AND CORRECT IIL❑ <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> APPLICANTS TIRE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# <br /> JURISDICTION# <br /> FACILITY q <br /> LOCATION CODE -OPTIONALs•ToG�Y� <br /> CENSUS TRACT .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 /> FORMA(9-90) <br /> FO <br /> FOg00]AA-R2 <br />