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AsAs <br /> As <br /> • STATE OF CALIFORNIA • hr <br /> STATE WATER RESOURCES CONTROL BOARD 3` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A Q � �: <br /> •C�(�FOR N�. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 t NEW PERMIT 0 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TE <br /> ONE ITEM [—] 2 INTERIM PERMIT [�] 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME //� NAME OF OPERATOR <br /> �o tG�/%re K 1�Od �+-t f} /Y2 H �7 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> / G /h.'S o✓r/ <br /> CITY NAME STATE ZIP CODE TE PHONE#WITH AREA CODE <br /> i G %Oma✓ CA <br /> TO DIC TE CORPORATION (]INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION a 2 DISTRIBUTORI/ IF INDIAN #OF TANKS AT7SITEE.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR a 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: tA4ME(LAST,FIRST) P,��ooNE#WITH AREA CODE DAYS:"ME(LT,FI T) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> WA/"I /`2 14 5 4 6,20V y6y"� -:'I %9�' �� �X _0 ?9--Lid <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREET <br /> "ADDRESS ✓box to indicate INDIVIDUAL E::] LOCAL-AGENCY (] STATE-AGENCY <br /> / <br /> ��v -t �(f /+�I���C� =CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 9 .v <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STR T ADDRESS may- %/box b indicate INDIVIDUAL LOCAL-AGENCY (�STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM /OST TE ZIP CODE PHONE#WITH AREA CODE <br /> 5 / O o�?/ �� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 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 /> F <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.a 111. <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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 67 - l8 I D G <br /> LOCATION CODE -OPTI NAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> D 23 - �v <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(9-90) FOR0033A-R2 <br />