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60V4 <br /> Oi STATE OFCAUFORNIA 'E <br /> STATE WATER RESOURCES CONTROL BOARD s ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C�l,�D1,YY <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F__j t NEW PERMIT O 3 RENEWAL PERMITS CHANGE OF INFORMATION O V PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE -L 1 <br /> I. FACILRYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 6p a - E� is /PFv 'sR . <br /> ADDRESS ` o � ^ NEAPESTSQ�STREET v� PARCELA(OPIIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 14_v1>� CA -2� <br /> v Box <br /> TOINDICATE O CORPORATION D INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY E__1 COUNTY-AGENCY STATE-AGENCY a FEDEML#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ) GAS STATION Q 2 DISTRIBUTOR ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aptionW) <br /> RESERVATION <br /> 0 3 FARM Q 6 PROCESSOR �HER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PUONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I,<;, -3 <br /> NIGHTS: NAME(LAST,FIRST) ONE#WITH ARE CODENIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I� Om v Z <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS .fr ✓bor b Vbkate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> < G/1!G �� O CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAMEPT STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) "/yL1Y <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓hmbMkzb INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> f �• Q CORPORATION = PARTNERSHIP Q COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAME STATER 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 4 4 -� <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.a it.O 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 MONTWDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION# FACILITY# <br /> LOCATION -OPTIONAL CENSU T# -OPTIONAL S45zo � <br /> THIS FORMISOR-DISTRICT CODE -OP77ONAL <br /> U <br /> jORMUST BE ACCOMPANIED BBY-S' <br /> Y AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR0033A Rz <br /> FORMA(9-90) A� <br />