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P�SOURkP.4 C <br /> STATE OF CALIFORNIA p A <br /> STATE WATER RESOURCES CONTROL BOARD 3 t�° X90 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A p; <br /> C421FOR NeP, <br /> 01 COMPLETE THIS FORM FOR EAC ACILtTY/Stt'E <br /> MARK ONLY Q I NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 02 INTERIM PERMIT Q 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D FACILITY�AME NAME OF OPERATOR <br /> ADDRESS, `G' �� <br /> / 7 NEAREST CROSS STREET PARCEL 9(OPTONAL) <br /> CITY NAMES STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5 vc- t� ca Z (ZDV} Rel �/® <br /> T I✓NDICAT <br /> pE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR RESERVA®ION OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR Z5 OTHERAta OR TRUST LANDS W..- <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) HONE#WITH AREA CO DAYS: NAME(LAST,FIRST) PHONE#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 /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSA, ✓ box topicals Q INDIVIDUAL Q LOCAL-AGENCY IQ STATE-AGENCY <br /> 00 //v 0 ® Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE P ONE# TH AREA CODE <br /> II. ANK OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME F OWNER / CARE OF ADDRESS INFORMATION <br /> M LNG RTR ET AD KESS, ✓ b Q INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> q5' v (�V( Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY 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 - <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: I.O 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 OATS MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FT__T71 lol®I ► I 8"6 P r-51 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL A. SU SOR DISTRICT CODE -OPTIONAL ( R <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 />