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�xcoua es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD t 'o <br /> �DERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 3 <br /> C1t�fO�N'� <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT CLOSED SRE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT E_] 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMELrNAME OF OPERATOR <br /> 57 AN Lz' F fC <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAU <br /> CITY NAME STATE <br /> eZIP CODE SITE PHONE#WITH AREA CODE <br /> 1u G <br /> ✓ <br /> TO INDICATE CA TE O CORPORATION (]INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUMYAGENCY D STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN j#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR = 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 /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blydbab O INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0idbats INDIVIDUAL D LOCAL AGENCY STATE-AGENCY <br /> O CORPORATION D PARTNERSHIP COUNTY-AGENCY O 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-F4]- i <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.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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> / 17 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z (0 7 % � <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) F72 <br />