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a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYSITE <br /> MARK ONLY 1 NEW PERMIT F7 3 ENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <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 /> 5 L�.A/D ST.ex<ET <br /> t��TE <br /> Ct/,s- <br /> CITY NAME ZIP CODEEPHONE#WITH AREA CODE <br /> 9s2os� KIP-- <br /> T NDIC TE [7)CORPORATION O INDIVIDUAL I1 PARTNERSHIPfV�LOCAL-AGENCY 0 COUNTY-AGENCY =1STATE AGENCY FEDERAL-AGENCY <br /> �"✓ tSTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#([primal/ <br /> RESERVATION ^� <br /> O 3 FARM O4 PROCESSOR 5 OTHER OR TRUST LANDS d <br /> .25 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> OAVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -1 e e5 2e 9 T- ss <br /> NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST)-PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> l Li> <br /> MAILING OR STREET ADDRESS ✓ box binEiate <br /> INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> S CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �T0 G ?15 9XF-'p-5741 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /✓IGER <br /> MAILING OR STREET ADDRESS box bindb9# INDIVIDUAL = LOCAL AGENCY INSTATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9 16)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - <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 FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED APPLICANTS TITLE DATE MONTWDAYNEAR <br /> r� xea oe <br /> LOCAL AGENCY USE <br /> COUK11'III JURISDICTION# FACILITY# �y <br /> / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL r 4 <br /> �- <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 /> FORM A B-90) FOBOMA R2 <br /> ////�\\N <br />