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STATE OF CALIFORNIA °. <br /> / STATE WATER RESOURCES CONTROL BOARD " ' o <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> y <br /> o <br /> COMPLETE THIS FORM FOR EAC. CILITYfSITE <br /> MARK ONLY I NEW PERMIT D RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLOSED SITE <br /> ONE REM 2 INTERIM PERMIT d AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME, / n NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFIONAU <br /> V37 E /Y�i;>zr <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S) k c Y;v^ CA 93'241/ — -o rr <br /> TO INDICATEQ CORPORATION INDIVIDUAL Q PARTNERSHIPQ LOCAL AGENCY Q COUNtt-AGE STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS = I GAS STATION Q 2 DISTRIBUTOR Q RE,' IF INANSERVATION OF TANKS qT SITE E.P.A. I.D.#(apAm#Q <br /> Q 3 FARM O A PROCESSOR Q 5 OTHER OR TRUST LANDS y <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 /> b� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S a . <br /> ` t <br /> . <br /> MAILING OR STREET ADDRESS ✓ Eo[bkwicaN Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSMP Q COUNrY.AGENCY Q FEDERALAGENCY <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 /> S4� <br /> MAILING OR STREET ADDRESS ✓ Ow bliNitala Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 4 F4 - D 3 a <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.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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/OAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 / 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE <br /> O/qF SITE INFORMATION ONLY. <br /> ��IpN�� / � 'A-R2 <br /> A(9-90) <br />