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STATE OF CALIFORNIA esoua<es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A " v o <br /> Xt l� <br /> COMPLETE THIS FORM FOR EACH FACIIJTY/SITE <br /> MARK ONLY 3 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY LOSED SR <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA ILITY MIME NAMEOFOPERATOR <br /> f S <br /> ADDRESS <br /> NEAREST CROSS STREET I PARCELN(OPrbNAI) <br /> � r <br /> CITY NAML I !� STATE ZIP CODE SI ;PHO Ex WITH AREA CODE <br /> ✓ BO% CA Q .. y <br /> TOINDICATE CORPORATION (] INDIVIDUAL O PARTNERSHIP (]LOCAL-AGENCY <br /> DISTRICTS � COUNTY-AGENCY [] STATE-AGENCY O FEDERAL-AGENCY <br /> TYPE OF BUSINESS O I GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.x toplipal) <br /> O 3 FARM O 4 PROCESSOR O RESERVATION <br /> O 5 OTHER OR TRUST LANDS <br /> EMERGENCY TACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATIO - MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> eldodr <br /> MAILTNGOFIQ CETAIDER S ✓barb kae D INDIVIDUAL I= LOCAL-AGENCY <br /> 01 0 STATE-AGENCY <br /> CITY N ME gPogATION = PARTNERSHIP 0 COUMY#GENCY Q FEDERAL-AGENCY <br /> STATE ZIP CO PHONE x WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Io Wma INDIVIDUAL = LOCAL-AGENCY <br /> 0 CORPogATION O FEDERSTATE-AGENCV <br /> CITU NAME <br /> PARTNERSHIP O COUNTY#WITH A C FEDEIIAL-AGENCY <br /> TATE ZIP DODE PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBE -Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and ling 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 NOTIFICATIO AND BILLING: <br /> I. II.O III. <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 MONTWDAYNEAq <br /> LOCAL AGENCY USE ONLY //lsI I <br /> COUNTY# JURISDICTION# !moi FACILITY# <br /> I�0 <br /> —LOCATION CODE -OPTIONAI. CENSUS TACT# -OPTIONAL SUPVISOR-DISTRICT CODES -OPTIONA`�--I(� <br /> f a <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) F G3A R2 <br /> q-- 1 - gam <br />