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""4°uN Cd <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH LfTYISRE <br /> MARK ONLY Q t NEW PERMIT F-13 RENEWAL PERMIT S CHANGE OF INFORMATION O 7 PERMANENTLY BED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> k C-� CA 1 9 5'3 3 <br /> I/ BOX TOINGCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q DISTRICTS LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR a ✓ IF INDTON <br /> IAN #OF TANKS AT SITE E.P.A. I.D.#(°plipra# <br /> Q S FARM 0 4 PROCESSOR Q S OTHER ORTRUST LANDS 7 <br /> _J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE#WITH AREA COOE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,Ave - 7y -8 0 <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> $R d^^4- dI S f- • <br /> MAILING OR STREET ADDRESS ✓64x 0YISKtlA Q INDIVIDUAL [] LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE d 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"Ic" Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q couNTYAGENCy Q 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) HQ4 4 - NIA <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bpx I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.= 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(PRNTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#� 5 Y 1'.)l"SS' <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT-OPTIONAL SUPVISOR-DISTRK:T CODE -OPTIONAL <br /> o a 3b� 3L3 6/zz/S � <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) Al FORMA <br />