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tsourtces <br /> STATE OF CALIFORNIA Ar r <br /> STATE WATER RESOURCES CONTROL BOARD 3 o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A01/ <br /> •cit lF°�M"�. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY � 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME \\ -- NAME OF OPERATOR <br /> v; l� S t0 a cb 1-t. <br /> ADDRESS r NEAREST CR SS STREET 9KRCEL#(OPTIONAL) <br /> S a. -cmtd <br /> CITY NAME STATE ZIP CODE S PHONJ#WITH AREA CODE <br /> ah Ae e-g CA z3- 76 zFt <br /> ✓ <br /> BOX <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY (]COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR a ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> K EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ' 71. lll <br /> NIGHT E(L FIRSTI NE#��CAREA CiO'SW7_� NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> >< <br /> �[ II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> (` NAM ` CARE OF ADDRESS INFORMATION <br /> LA.I <br /> MAILING OR STREET ADDRESSbox b' icate INDIVIDUAL (] LOCAL-AGENCY =STATE-AGENCY <br /> ✓ <br /> V � —7 Ll CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY = FEDERAL-AGENCY <br /> I AME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Q C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 1 CARE OF ADDRESS INFORMATION <br /> V i 6� <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> fJRPORATION = PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CI AME STATE ZIP CODE PHONE#WITH AREA CODE <br /> v0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 1 1716 <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: 1.0 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# QUI 0 570 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 1/4- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SUITE INFORMATION ONLY. <br /> FORMA(9-90) <br /> FOR0033A-R2 <br />