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resoua es <br /> �./ STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> OaY.a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 T NEW PERMIT O 3 RENEWAL PERMIT Ea6CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADD SS NEARESTCROSS STREET PARCEL#(OPTIONAL) <br /> CITY N� � STATE ZIPC 7� SITE PHONE WITH AREA CODE <br /> CA <br /> BOX TOINOCATE D CORPORATION INgVNXIAI 1 PARTNERSHIP �LOCAL-AGENCY (�COUNTY-AGENCY STATE-AGENCY FEDEML#GENCY <br /> DISTRICTS V INDIAN <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR 0 RESE1RVATTION #OF TANKS AT SITE E.P.A. I.D.#(apkn#q <br /> Q 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#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 /> ya II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /d// SL S <br /> MAILING OR STREET ADDRESS _�^ ✓box thkala -INDIVIDUAL ADDRESSEDbox0 STATE-AGENCY <br /> 3 �r �J (� [I]CORPORATION PARTNERSHP E] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NA O��GK S/ ZIP PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED fi l <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> a OL�iaie.EZ <br /> MAILING OR STREET ADDRESS r` L box b#bbab IVIDUAL I� LOCAL-AGENCY O STATE-AGENCY <br /> 3 �, eaj 7 �QI/( . 0 CORPORATION PARTNERSHIP 0 CWNTYJGENCY FEDERAL-AGENCY <br /> CITY NAME5� STATE ZIP CODE PHONE#WITH AREA CODE <br /> ria o� 1e, <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-F4 -1 I I -F= <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.O II.O 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR WTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAW/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN!!Y# JURISDICTION A FACILITY <br /> D <br /> LOCATION CODE -OP710NAL CENSUS TRACT;-OP770NAL SUPVISSOR pI3TRK:T CODE -OPTKINAL -7- / 4� <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 /> FORW33A R2 <br /> FORM A(9-90) <br />