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,OUR PS <br /> STATE OF CALIFORNIA P <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a <br /> C�LIfOP Nor <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 3 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE Q� <br /> e' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) �( <br /> DBA OR FACILITY N E NAME OF OPERATOR / <br /> V i k S� a /r A f /� <br /> ADDRESSl NEAREST CROSS STREE PARCEL ( - <br /> CITY NAME STATEaOE 6 VE PHON #WITH AREA CODE <br /> C s ca 33n3-762 <br /> TO INDICTE RATION [] INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY (] STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION a 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(L IRST) P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ` o - 57- ° <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME nCARE OF ADDRESS INFORMATION <br /> V t C- <br /> MAILING OR STP T AQDRE ✓ taz to i icate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> lJ^J\ CORPORATION = PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATS ZIP CODE y 5 � � F51�#WITH AREA _ <br /> ..-r�p Cp 6 5 �rS <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER M CARE OF ADDRESS INFORMATION <br /> 1� <br /> MAILING OR STREET ADDRESS ✓ box bindicate (] INDIVIDUAL LOCAL-AGENCY <br /> STATE-AGENCY <br /> Q CORPORATION E�] PARTNERSHIP COUNTY-AGENCY [] 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 [4T41_1v1t III <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.[�] II. 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# <br /> F_�_ � STT► � y z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVI2R-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 SITE INFORMATION"ONLY. <br /> FOR0033A-R2 <br /> FORM A(9.90) <br />