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STATE OF CALIFORNIA <br />STATE WATER RESOURCESCONTROL BOARD <br />UNDERGROUND GE TANK PERMIT APPLICATION - FORM <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY F-1 t NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PER <br />ONE ITEM F7 2 INTERIM PERMIT 0 4 AMENDED PERMIT [:j 6 TEMPORARY SITE CLOSURE <br />�6pURC�s <br />M1PP nvnene CpA <br />3 9a <br />� A <br />• C,[IfOR NtP •. <br />DBA O FACILITY NAME <br />CARE OF ADDRESS INFORMATION <br />NAME OF OPERATOR <br />✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />ADDRE <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />t <br />CITY NAM <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />ICA <br />TO INDICATE Q COR ATION <br />Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY <br />Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS ,GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optiatal) <br />3 FARM <br />RESERVATION <br />4 PROCESSOR Q 5 OTHER I OR TRUST LANDS <br />1 r i L tf Lr; r1, r <br />EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />E (LAST. FIRST) /7., ® PHONE # WITH AREA CODE <br />z <br />�q AREA CODE <br />11 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION • (MURT RE' I PLET n1 <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box IDindicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />21P CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUVT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (T) H 4 4 - <br />V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal noti ' 2tion and billing will be sent to the tank owner unless box I or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. U H. a 111, 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 MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY <br />//# <br />afffl( <br />LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR RE PERMIT APPLICATION • FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A (9.90) ��' FOR0033A-R2 <br />