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. • •STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD ID UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYSITE <br /> MARK ONLY a I NEW PERMIT 3 RENEWAL PERMIT EgS CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATO <br /> R. _ ge,,4a 45 I" 044 <br /> ADDRESS NEAREST CROSS STREET v ARCEL IOPTIONAU <br /> H E. Mqrr L,5,� <br /> CITY NAME STATE ZIP CODE f SITE PHONE#WITH AREA CODE <br /> S r o4-) CA 520 <br /> r <br /> BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL = LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTORRE.1 IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. L D.#(optimal) <br /> Q 3 FARM Q 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 CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> f <br /> MAILING OR STREET ADDRESS Lor b Indicate D INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP O COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Wxb'Mbba D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH 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 unlesq box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.0 III.O <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 S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> USi2E1�1`� L� <br /> LOCATION CODE -OPTIONAL-A--LL CENSUS TRACT# -OP770ML SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z� 3.4sd 3.2-5 zs C <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 /> FOfl0077AA2 <br /> FORM A(5-90) \ <br />