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O RM C <br /> STATE OF CALIFORNIA Ac <br /> STATE WATER RESOURCES CONTROL BOARD P , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •C�(II°R N' <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 3 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [::] 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE /4 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) V <br /> DBA OR FACILITY NAME NAME OF OPERATOR/� <br /> .io© fes. rv/l of C.- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> �f7 Lex r N XC <br /> CITY NAME - STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> LO thr-o CA ?5330 zoo - 85$ -,2666 <br /> ✓ Box <br /> TO INDICATE O CORPORATION (]INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F__j 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.'#(optional) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <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 /> If. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME �C CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL <br /> LOCAL-AGENCY E=j STATE-AGENCY <br /> 19-3 MaN 2 (]CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME _ STATE ZIP COD �� 7[P �_HITH AREA CODE <br /> M �..C4 953 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /' <br /> MAILING OR STREET ADDRESS ✓box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE it WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4T4]-61.zl <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank ow n ess b I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.0 III. <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 /> 3 C1R t8' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> D 3 3Z <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 /> N <br />