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• • °°�,,..,i c <br /> STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA >P <br /> •CPl1iOPN,i <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITES <br /> MARK ONLY a TEMPORARY SITE CLOSURE Sd e <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OP RATOR <br /> DBA OR FACILITVN 1 erg 4 H <br /> ('✓ll f'�'L 0�n PARCELO(OPTIONAL) <br /> NEAREST CROSS STREET <br /> ADDRESS (+, <br /> 'tel ITE PHONE x WITH AREA CODE <br /> CITY NAME STATE ZIP CODE <br /> ,�� �n ca 9 s 36G zos SSS- 2 �1Z <br /> '1 BO% ORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> ✓ IF INDIAN #OF TANKS SITE E.P.A. I.D.#(optional) <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR �a TTHER OR TRUST LANDS <br /> PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> EMERGENCY CONTACT HAREA CODE <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WIT <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME h j l f-V-t 5 ✓ boy tlMtaw INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADD^SS CORPORATION PARTNERSHIP = COUMYAGENCY FEDERA4AGENCV <br /> CITY NAME ,ff1 ` 5T�9 ZIP CAS �� P ONE#WITH ARE`-ARCS E /S3 <br /> 5� O <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OW NER '�❑ <br /> c I✓l C �•S ^ ✓ ror t meicau <br /> MAILING OR STREET ADDRESS = 1 <br /> NDIYIWAL LOCAL-AGENCY O STATEAGENCV <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY I2 FEDERALAGENCY <br /> STATE ZIP CODE PHONE#WITH AREACODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 it questions arise. <br /> TY(TK) HQ 4 4 - O S <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: <br /> I.❑ IT.�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 8 SIGNATURE) <br /> APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# <br /> JURISDICTION# FACILITY# `,y' '� T',t�STI <br /> I <br /> IL—ll�l JI SUPVISOR-DISTRICT CODE -OPL�TIONALL -3 <br /> LOCATION CODE -OPTI�AL CENSUS T==TZ OPTIONAL <br /> THIS FORM MUSTBEACCOMPANIED BY AT LEAST(1)0R MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OORoY7ARz <br /> FORMA(9-90) //�j <br />