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thou. e <br /> STATE OF CALIFORNIA Ar' '""�"' cow <br /> STATE WATER RESOURCES CONTROL BOARD 3• <br /> UNDERGROUND STORAGE TANK PER71ACIL11YIS11E <br /> PLICATION- FORM A <br /> o <br /> C�t�ION N� <br /> COMPLETE THIS FORM FOR EA <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DOA OR A LITY NAME % N E OF 0 <br /> PERAT,OLl <br /> )i <br /> ADDR !' i , MNEAREST CROSS PARCEL If(OFTONAL) <br /> W� ' ..r7_ <br /> CITY NA STATE ZIPSI E PHONE# ITH AREA DE <br /> ca - —7� 3 <br /> T NDCATE O CORPORATION (] INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY (] COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 3 GAS STATION 2 DISTRIBUTOR ✓ IF INDN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATIOIAN �+.. <br /> a 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> A > / � /��m ��� / CARE OFS�NFO MATION1111 .A / •�� 1 <br /> R S FEET DD SS ✓ box b indicate 0 INDIV UAL G/(J L/ <br /> 1 /q�E p = LOCAL-AGENCY STATE-AGENCY <br /> IDD; <br /> �� ✓�r lie_ CORPORATION = PARTNERSHIP = COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY, NAME STMEZIP E PHONE#WITHEA COD✓�� <br /> t,0,5 4,de'l, <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW RG CARE OF ADDRESS INFORMATION <br /> 71 <br /> MAILING OR STREET ADDRESS ✓ ✓ box b indicate 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN 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 -101 Q <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 114- 'ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING:THIS <br /> I- <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 4t JURISDICTION# FACILITY# <br /> VA110N 2 <br /> LOCATIONfiO E -OPTIONAL CENSUS TRACT-O�IONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> (°�) 2 d 3-z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGEOF RE INFORMATION ONLY. <br /> FORM A(9-90) Z FOR0033A-R2 <br />