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STATE OF CAUFO A P A <br /> STATE WATER RESOURCES CONTROL BOARD 3� <br /> APPLICATIONUNDERGROUND STORAGE TANK PERMIT - o <br /> a: a <br /> COMPLETE THIS FORM FOR EACH FACT /SITE <br /> ARK ONLY DS I NEW PERMIT 0 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITE E::] 2 INTERIM PERMIT a 4 AMENDED PERMIT a S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION -(MUST BE COMPLETED) <br /> DBA 0 FACILITY E NAME OF OPERATOR <br /> Sm <br /> ADDRESSNEARE TCRO STR ET PARCEL#(OPTIONAL) <br /> f U <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lo CA oct <br /> TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM (� 4 PROCESSOR 5 OTHER OR TRUST DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(L T8,FIRSD PHONE#W H EA OD DAY NAM (LAST,FIRST) INE#WITH AREA CODE <br /> � <br /> NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE NI TS: NA E(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATICN- MUST BE COMPLETED) <br /> NAMTXff CARE OF ADDRESS INFORMATION <br /> OLE <br /> l( t <br /> MAILING OR STREET ADDRESS ✓box to Indicate Q INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> faminu Ramon RPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME t STATE. ZIP CO E 6PNE# ITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME WNE c CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Wxbindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMEp ST ZIP CODE PHONE#WITH AREA CODE <br /> esn <br /> IV.BOARD OF EQUALIZATION USTFEE ACCCUNT NUMBE9-Call(916)739-2582 if questions arise. <br /> T (T ) HO 4 -10 101 1 1��� <br /> V. LEGAL NTIIC TI ILLI ESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> E <br /> HECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[�j it. 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 A SIGNATURE) rAP;PUd_ARrB TITLE DATE MONTH/DAY/YEAR <br /> LCL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> 6 /2- <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSOR-DISTRICT CODE -OPTIONAL <br /> SUPVI <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 /> FORMA(9•90) <br /> FOR0033A-R2 <br /> - ) 'G� , <br /> f <br />