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�SoUR es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a m g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a� �. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> G{ Ids <br /> ADDRESS NEAREST CROSS STREET PARCELS(OPTIONAL) <br /> CITY NAM STATE ZIP fODE SIjF PHONE#WITH AREA CODE <br /> c) CA <br /> TO INDICATE F-1 CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION 0 2 DISTRIBUTOR O SEIF <br /> INDDIAN #OFT KS AT SITE E.P.A. I.D.0(optimal) <br /> O 3 FARM 4 PROCESSOR M/5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE&WITH AR ODE DAYS: (LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAM (LAST,FIRS NE// PHOWITH ARE 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 ✓ box lo indicate INDIVIDUAL <br /> (] E=1 LOCAL-AGENCY E:j STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE __TZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERS -' CARE OF ADDRESS I FORMATION • <br /> 'ateFar- 1 aits <br /> MAIING OR STREET ADDREW ✓ box to indicate = INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> �13 0-kE ' n t7-P— =CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITU NAM STATE �� � � PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HOF4 4 - 01;. Y 4 c( 7 <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.E] 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 a SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIO L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF I RMATION ONLY. <br /> FORM A(9-90) FOR0033A-R2 <br /> o ��-r.� <br />