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• • oua e <br /> STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD x` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A »o <br /> " <br /> COMPLETE THIS FORM FOR EACH CILTTYISITE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITYN �// -''^^ NAMEOFOPERATOR <br /> �1 a <br /> ADDRESSNEAREST CROSS STREET PARCEL%(OPTIONAW <br /> 4OA& <br /> CITY NAME— r ��� STACA ZIP CODE SI�PHOONE W TN&AREAA CO . � <br /> TOINDICATECORPORATION 0 INDIVIDUAL =PARTNERSHIP D LOCAL-AGENCY (] COUNTY-AGENCY STATE-AGENCY �(� FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR = RE/ IF INDIAN SERVATION x OF TANKS AT SITE E.P.A. I.D.%(apthnaq <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: AME( T.FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AAA ao - a o <br /> NI H S: NAMEILAST.FIR PHONE WITH 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 /> MAILING OR STREET ADDRESS ✓ boa bindic b Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q 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 ✓ boa 104idbab INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP (] COUNTY#GENCY Q FEDERAL-AGENCY <br /> CITY NAME TATE 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 K41- O <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.❑ II.O III.O <br /> THIS FOAM 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY L60LIF0 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONCODE -OPTIONAL CENSUS TRACK# -OPTIONAL SUPVISOR��� E -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST((111)J)OO,R MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS CHANGE OF SITE INFORMATION ONLY. <br /> FOROW3AR2 <br /> FORM A(9.90) <br />