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•t60UR p° <br /> • STATE OF CALIFORNIA • ,e c°„ <br /> STATE WATER RESOURCES CONTROL BOARD ;° 4 <br /> n UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> C <br /> COMPLETE THIS FORM FOR EAC CIUTYISITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PEFINU%NrlLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE a <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME . NAMEOF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> , C1/9A CA <br /> TI/ BOX <br /> l�CORPORATION Q INDIVIDUAL = PARTNERSHIP D LOCA- GENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> CTS <br /> TYPE OF BUSINESS ( GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.N(opfianal) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR OTHER OR TRUST LAND$ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) NONE#WITH AREA CODE DAYS: NAME(LAST,FIRSn PHONE#WITH AREA CODE <br /> e > 767 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WtTH 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 /> - �o CA: (� <br /> MAILING OR STREET ADDRESS ✓ hoa blMicaN [:] INDIVIDUAL D LOCAL AGENCY D STATE-AGENCY <br /> (90 CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 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 ✓ bubiWitib = INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD O OUALIZATION UST STORAGE FEE CCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) H 4 4 - a 3 <br /> V. LEGAL OTIFICATION AND BILLING ADDR Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE 80XI ATING WHICH ABOVE EHE <br /> BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II.0 U. <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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# NroN <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a3S-) 7 <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 /> FORA R2 <br /> FORM A(9-90) � <br />