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• eayooa en <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT G RENEWAL PERMIT ❑ 5 CHANCE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT D S TEMPORARY SITE CLOSURE O <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAO/R FACILITY,^NAME - -WANE_0F OPERATOR <br /> T Q7 df Nf <br /> ADORE NEAREST CROSS STREET PARCEL 0(OWgNAL) <br /> !9,0/0 <br /> v <br /> CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> Box oc CA �j5.to3 X09-`!66 <br /> TOINDC TE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNrYAGENCY ' <br /> DISTRICTS STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS a i GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.s(goiioneq <br /> Q 3 FARM O d PROCESSOR ATIO <br /> Q S OTHER a OR TTRUSTVLANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ll�� �' CAREOFADDRESS INFORMATION <br /> FGYf'SiGT.G r1rv. i.5� 1c- /_C_ . <br /> MAILING OR STREET ADDRESS _ [ ✓box m INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> .2S _ O CORPORATIONPARTNERSHIP D COUNTY-AGENCY E3 FEDERAL#GENCY <br /> CIN NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> 64szo z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF O WNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ooa biMkau lj INDIVIDUAL 0 LOCAL-AGENCY <br /> O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <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.O II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS <br /> (PRINTED A,SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY at <br /> LOCATIONCODE -OPTIONAL CENSUS TRACTS -OPTIONAL (STRICT DE -OPTIONAL <br /> � s, �� 3zs zr C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATI O ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9-90) FOR=3A-R2 �, <br />