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f <br /> eebou• ey <br /> STATE OF CALIFORNIA <br /> i <br /> STATE WATER RESOURCES CONTROL BOARD W mom! e <br /> �DERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 3 v, <br /> e . ; <br /> e�l,l'Ol�e��� <br /> COMPLETE THIS FORM FOR EACH F ILrTY1SrTE <br /> MARK ONLY Q T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT d AMENDED PERMIT O a TEMPORARY SITE CLOSURE If <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> [1 n. rnec� <br /> ADDRESS NEAREST CROSS STREET PARCEL/(OPTIONAL) <br /> r5 W <br /> CITY NAME rSTATE ZIP CODE PHONE N WITH AREA CODE <br /> C�k/v CA 1 95 tor- <br /> T I/ BOXTE 0 CORPORATION 0 INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY [� STATE-AGENCV WY <br /> DISTRICTS <br /> TYPE OF BUSINESS O i GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE I E.P.A. I.D.#([PHarW) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) PERSON (SECONDARY)-optlonal <br /> DAYS: NAME ST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> lir^7 �" Zr /Yl <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE GHTS: NAME LAST FIg3 PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> W int Q Z <br /> MAILING OR STREET ADDRESS ✓ box bindkaM 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 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 /> St. .n ti s .2- <br /> MAILING OR STREET ADDRESS bm 0 14k O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION D PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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 11 is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III.F7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTEDB SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# zreepe 13 <br /> F311 I aS- <br /> LOCATION CODE -OPTIONAL CENSUS TRACTSUPVISOR-DIS <br /> -OPTIONAL TRICT CODE -OPTIONAL <br /> o c)- 3S--D 335- <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(& FOROMA-92a0) (/ <br /> ,rtiUL. <br />