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0 eSou <br /> STATE OF CALIFORNIA • Ar r ."...."�"' �Ot„ <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A jib� <br /> COMPLETE THIS FORM FOR EA ACILITYISITE `4ti.o«N' <br /> MARK ONLY 0 I NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SrT <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 96 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB,"R FACILITY NAME NAME OF OPERATOR <br /> ADD / r1�/�� NEARE T ROSSST�iEETj r PARCEL#'(OPTIONAL) <br /> CITY M ,F/ STATE w,Z(I/P1CODF— SITE PHONE XWITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICTE I7 CORPORATION INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTORR SER ON <br /> INDIAN #OF TAfj�(S AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP 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 9.FOOWNER CARE OF ADDRESS INFORMATION <br /> 0-f an <br /> ►Y1 G OR STEET ADDREES ✓ box bindicate = INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> d Co <br /> (]CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CI AME STATE ZIP PHONE#WITH AREA CODE <br /> W ���� <br /> I .BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - Q 2 Z <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. 1 <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II.0 III. <br /> VI <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 57 _'557vt__W � o <br /> LOCATION COD - TIONAL CENSUS TRACT* -_OPTION SUPAOR-DISTRICT CODE -OPTIONAL <br /> 23i I <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 /> i <br />