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MARK ONLY <br />ONE ITEM <br />9�50U.Ces <br />STATE OF CALIFORNIA M1P P <br />STATE WATER RESOURCES CONTROL BOARD a , <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />• C,(IfoP N,� <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />r7 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSE <br />0 2 INTERIM PERMIT F__1 4 AMENDED PERMIT �<6 TEMPORARY SITE CLOSURE T_<'�f <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILI�1 NAME . <br />rL7 <br />Fact11— <br />Lfu ill-// <br />/ / <br />LOCATION CODE -OPTIONAL <br />NAME OF OPERATOR <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />ADDRESS <br />/ <br />MAILING OR STREET DRESS I <br />STATE <br />NEAREST CROSS STREET <br />O LOCAL -AGENCY L_j STATE -AGENCY <br />PARCEL#(OPTIONAL) <br />�&� <br />�t <br />COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME{ <br />STATE <br />ZIP CODE <br />CITY NAML <br />PHONE # WITH AREA CODE <br />STATE <br />CODE <br />SITE PHONE # WITH AREA CODE <br />G <br />TZIP <br />CA <br />✓ BOX <br />TO INDICATE <br />( CORPORATION <br />77��� <br />0 INDIVIDUAL 0 PARTNERSHIP <br />0 LOCAL -AGENCY 0 COUNTY -AGENCY <br />STATE -AGENCY FEDERAL -AGENCY <br />7 <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />3 FARM <br />4 PROCESSOR 0 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />NA (LAST, FIRST) PHONE # WI H AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />'.S d 0 G -54'Y_3 <br />LOCATION CODE -OPTIONAL <br />IGHTS: NAME (LAST, FIR HONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFO ATION <br />LOCATION CODE -OPTIONAL <br />MAILING OR STREET ADDRESS <br />✓ box IDinditM INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />MAILING OR STREET DRESS I <br />STATE <br />ndicate E:D INDIVIDUAL <br />O LOCAL -AGENCY L_j STATE -AGENCY <br />�&� <br />CORPORATION = PARTNERSHIP <br />COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME{ <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />FACILITY # <br />LOCATION CODE -OPTIONAL <br />MAILING OR STREET ADDRESS <br />✓ box IDinditM INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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 F4 -F4-1-1010106 <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. 0 II.1W III. a <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 MONTHlDAYNEAR <br />LOCAL AGENCY USE ONLY AA n h, I I Q - <br />COUNTY # <br />JURISDICTION # <br />FACILITY # <br />LOCATION CODE -OPTIONAL <br />CENSUS TRACT # -OPTIONAL <br />SUPVISOR - DISTRICT CODE - OPTIONAL <br />1 L. -I! I [.0"N ✓ If F A l—F I C;;_ 1 <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 Y. <br />R0033A-R2 <br />FORMA (9-90) — � _7 <br />