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SOUR <br /> C <br /> STATE OF CALIFORNIA Ar P <br /> STATE WATER RESOURCES CONTROL BOARD 3` . <br /> .UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH F LITYISITE <br /> MARK ONLY 0 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F—] 2 INTERIM PERMIT 0 4 AMENDED PERMIT E�:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIL TY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 5 / us- �vei�l E 1"944A- <br /> CITY s�L <br /> CINAME <br /> -� STATE ZIP CODE Ztzj #�WITH�ARE-71 0� <br /> lIBOX <br /> TOINNDIICC TE CORPORATION INDIVIDUAL (] PARTNERSHIP [�LOCAL-AGENCY Q COUNTY--AAGENCY STATE•AGEENNCY�2f,/(] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 I GAS STATION [::] 2 DISTRIBUTOR ✓ IF INDIAN l#OF TAN AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ICJ 5 L <br /> Q 3 FARM 4 PROCESSOR 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 /> v %7''I//U <br /> NIGHTS: NAME(LAST,FIRST) HONE#WITH ARJiA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> s — <br /> MAILING OR STREET ADDRESS gy�pp'' ✓ box icate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> D G� � �/�� ORPORATION = PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> y� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS A�� Q ✓box b cue INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> gq.40 /yam e.; �i�A CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME 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 Oecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.Z111. <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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# AlW <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL / 1' q <br /> 01- �3.0 0 �Zv <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 />