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STATE OF CALIFORNIA valor <br /> STATE WATER RESOURCES CONTROL BOARD + ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� <br /> O Nf <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT E7r5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 7 i <br /> _WY STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> TOIN ICABOX CORPORATION INDIVIDUAL 0 PARTNERSHIP ANLAG3 CY COUNTYAGENCY 0 STATE-AGENCY FEDEML#GENCY <br /> TYPE OF BUSINESS T GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(apbonal) <br /> RESERVATION /v <br /> O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAVE: 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 /> MAILING OR STREET ADDRESS ✓ bmbintleL# 0 INDIVIDUAL 0 LocAL-AGENCY O STATEAGENCY <br /> 0 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY = 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 SWEET-ADDRESS ✓ box bin&k INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP E_j COUNTYAGENCY E-1 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 4U4 -1 o I kj (fs e 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: I. I Y II.O 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 B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 111 FACILITY# 57( < '- )jONLY.FsDLOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONALTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> FORM A(9-90) Noe <br /> FOR00]9A <br />