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itsouRces <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISrrE <br /> MARK ONLY 0 T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME )) // NAME OF OPERATOR <br /> '5 .7C! N r i1- V^^,,I-J <br /> ADDRESS / NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> J r �lLe >4 -h,Jf i)DPN -G1 <br /> CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> 4—r-i rnr CA 1q5 3 j'% /,Lcl� <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY (j[� FEDERAL•AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS T GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.r(optional) <br /> a = RESERVATION <br /> Q 3 FARM a 4 PROCESSOR Q 5 OTHER OR TRUST LANDS j <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: J T1j r 1 C.r^ PHONE tX WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> r vcll` �?1-IC He,rNl-'s ✓r-TC� „1Cr.. ?L-Z-.�Zt"�rI <br /> NIGHTS: NAME(LAST.FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S�_Ir_W e di5 ,L <br /> MAILING OR STREET ADDRESS ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bub!cate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 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: 1. 11. 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 S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 2w`& <br /> F771 IC3 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �y <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SMATION ONLY. <br /> a FOR0035A-R2 <br /> FORM A(9-90) `' <br />