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�boue ey <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> r o <br /> COMPLETE THIS FORM FOR EACH FACILRYSITE <br /> MARK ONLY F-1 r NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION EV 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 1)RlAr NAM i_ " NAME OF OPERATOR <br /> ADD E B NEAREST CROSS STREET PAACEIa(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> GL' '1 CA <br /> I/ BOX <br /> TOINDIIC TE O CORPORATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 ) GAS STATION 0 2 DISTRIBUTOR pE/ IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST( PHONE a WITH AREA CODE 7= <br /> T,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa b indicate ED INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION O PARTNERSHIP cOUNrY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Inkate = INDIVIDUAL O LOCAL-AGENCY I3 STATE-AGENCY <br /> CORPORATION E--1 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 F4-[-4]- 2 �p <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thelank 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 11.O III.O <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# +��i'�✓� JURISDICTION# FACILITY# <br /> � -�=-_1_H D �4 <br /> LOCATION COp@ -�710NAL CENSUS TRACTi -DPI TI AL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> U 23 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 /> FORM A(9-90) FOROW- <br />