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P�'0" <br />STATE OF CALIFORNIA M1r <br />STATE WATER RESOURCES CONTROL BOARD a o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />4 <br />• C�(IfOP N� . <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY (�?f , NEW PERMIT F—] 3 RENEWAL PERMIT F__] 5 CHANGE OF INFORMATION [�] 7 PERMANENTLY CLOSED SITE <br />ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME// <br />ei_. _ 01 <br />NAM`_EE OFOPERATOR <br />is o to l_ �;W I <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />6&�_ <br />sic <br />NI HTS: NAME (LAST, FIRST) <br />CITY NAME <br />D 1 <br />STATE <br />CA <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />3155 <br />I/ Box <br />TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY 0 STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESSEj;j0'*1_GAS STATION a 2 DISTRIBUTOR✓ <br />IF INDIAN <br />1# OF TANI AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM a 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />PHONE # ITH AREA CODE <br />Mb -1414 <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARYi - oofinnal <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />11 <br />MAILING OR STREET <br />6&�_ <br />sic <br />NI HTS: NAME (LAST, FIRST) <br />P�%, <br />NE# WITH ARE -A7 CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />*A <br />IUB <br />p <br />& ! ) <br />MCORPORATION 0 PARTNERSHIP <br />11. PROPERTY OWNER INFORMATION - (MURT RE COMPLETEDI <br />NAME <br />SSI✓ <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />11 <br />MAILING OR STREET <br />DDRESS <br />sic <br />MAILING OR STREET ADDRESS <br />` <br />02 RPORATION Q PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />✓ box toindicate INDIVIDUAL <br />LOCAL -AGENCY Q STATE -AGENCY <br />13 hII" <br />I <br />PHONE # ITH AREA CODE <br />MCORPORATION 0 PARTNERSHIP <br />COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />4coe <br />— 14A J <br />STATE <br />CJS <br />ZIP CODE <br />q4 i�7zj2� <br />PHONE # ITH AREA CODE <br />Mb -1414 <br />TANK OWNER INFORMATION - (MUST RE COMPLETEDI <br />NAME OF OWNER !!1 <br />CARE OF ADDRESS INFORMATION <br />DATE MONTH/DAY/YEARt <br />11 <br />MAILING OR STREET <br />DDRESS <br />✓ box to indicate = INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />02 RPORATION Q PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME MEy <br />C6 <br />STATE <br />/lah%' <br />ZIP CODE <br />PHONE # ITH AREA CODE <br />�+' <br />— 14A J <br />IV. BOARD CF EQUALIZATION UST STORAGE FEE. ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (TK) HQ F4t_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. 0 II. a III. N�� I <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & SI RE) <br />APPLICANTS TITLE <br />DATE MONTH/DAY/YEARt <br />11 <br />I�l't' �c, e s� <br />I <br />LOCAL AGENCY USE ONLY <br />COLINT Y # JURISDICTION # FACILITY # <br />m Fm �m <br />LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <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 />FORM A (9-90) FOR0033A-R2 <br />is 0 <br />