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`W STATEOFCAUFORMA W/ eebpO" e <br /> STATE WATER RESOURCES CONTROL BOARD a�+ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> G COMPLETE THIS FORM FOR EACH FACILITYISrTE ^ "�^. <br /> MARK ONLY E�l I NEW PERMIT 3 RENEWAL PERMIT <br /> 0 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM E] 2 INTERIM PERMIT [—_] 4 AMENDED PERMIT ED a TEMPORARY SITE CLOSURE <br /> (31 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> m Iccx N- F�>ra{ Pn <br /> ADOR SS NEAREST CROSS STREET PARCELt(OPTMNiAU <br /> a o� s <br /> CITY NAMEOC 7b.AJ STATE ZIP CODE SITE PHONEt WITH An 00DE <br /> 11 szo <br /> ✓ Box <br /> TOINDICATE E71 CORPORATION O INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY O CDUNTYAGENCY D STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.•(opipa/j <br /> 3 FARM O 4 PROCESSORATION <br /> O 5 OTHER ORRTRUST VLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST( PHONE t WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODENIGHTS: NAME(LAST,FIRST) PHONE t WITHAREACODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATIQN'L <br /> MAILING OR STREET ADDRESS ✓box bbdb L-J INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 650I� PARTNERSHIP <br /> ON �CORPORATIONQ COUNTY-AGENCYQ FEDERAL-AGENCY <br /> CITY NAME STATE <br /> r�� ZIP DE PHONE s WITH AREA CODE <br /> 3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED OWNER CARE OF ADDRESS INFORMATION <br /> � <br /> s <br /> MAILING OR STREET ADDRESS ✓borbindoalc I� INDIVIDUAL =LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION PARTNERSHIP Q CouNTY+L3ENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A 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 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 hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.a 11. 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 A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILQY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACTA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> S FORM M BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMJA R2 {1. <br /> FORMA(9-90) � <br /> .i �� <br />