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�y°URces <br /> STATE OF CALIFORNIA A�p <br /> STATE WATER RESOURCES CONTROL BOARD <br /> /' , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 4 <br /> 6 <br /> •C�(IfoR N��. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F__� 1 NEW PERMIT F—] 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 0 7 PERMANENTLY <br /> ONE ITEM 0 2 INTERIM PERMIT F7 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE ( f <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME: NAME OF O ERATOR <br /> U t Q S 1 `7 at rye S �G l <br /> ADDRESS NEARESTC OSS STREET PARCEL#(OPT AL) <br /> `7 SC o4'1 1f va <br /> CITY NAME STATE ZIP dODE PTE PHONE#WITH AREA CODE <br /> 1("\ G� Vec9 CA S33G y73-733 <br /> T NDIICO TE ORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR0RE/SERVATION <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> �J <br /> 0 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#WITH AREA CODE <br /> Cr"v-t� J e,-les Z,64 Y7.3--7337 <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 /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Vj k 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �\ <br /> NAME OF OWNE C /� CARE OF ADDRESS INFORMATION <br /> Uvtv Ca d( ✓l 4De (f'clM h4,'y 4 l <br /> MAILING OR STREET ADDRESS ✓box b indica <br /> n � INDIVIDUAL Q LOCAL•AGENCY Q TATE-AGENCY <br /> ql A s\'-'r1 re_ U/j l(! U CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY' <br /> CITY NAME STAT ZIP CODE HONE#WITH AREA CODE <br /> n n [c Dv/ z13 `177- 06 3 <br /> IV. BOARD OF EQU LIZATION 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 is checked. <br /> F <br /> ECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS-SEEN COMPLETED UNDER—PENALTY OF PERJURY AND TO THE BEST F MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# V 10W 7 <br /> S <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> © 5 a3g—C) zC <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 /> FORMA(9-90) �� <br />