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'�60VR <br /> yV STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> \ / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA •;p ,.,; o, <br /> V� // C-tiO1Mi <br /> COMPLETE THIS FORM FOR EAC ACILTTYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF CILITYNAME J NAME OF OPERATOR <br /> ADDRESS NEARESTCROSS STREET PARCEL#(OPTIONAL) <br /> s <br /> CITY NAE STATE ZIP E SITE PHONE%WITH AREA CODE <br /> CA S a <br /> TOIN BOX Q CORPORATION INDIVIDUAL Q PARTNERSHIP E3 DISTRICTS <br /> Q COUNTY-AGENCY O STATE AGENCY I� FEDERAL-AGENCY <br /> ❑ 2 DISTRIBUTOR ❑ RESERVATION %OF TANKS AT SITE E.P.A.RESERVATION% (aplbnal) <br /> TYPE OF BUSINESS W1 GAS STATION <br /> 3 FARM ❑ 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 /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIN RSTREET AD ESS ✓ box b1ndsa% INDIVIDUAL O LOCAL-AGENCY El STATE-AGENCY <br /> S' hI E3 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE%WI AREA CODE <br /> S S. C 3 �to8 5 -3 s <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box bkXACM INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> 4 <br /> TY(TK) HQ 4 -ba ff 5 'c—�'(� <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 8 DUNG: I.❑ II. 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 Iffl4h ; 17,5 <br /> COUNTY% JURISDICTION p FACILITY a <br /> � 00 <br /> LOCATION LODE -OPTIONAL CENSUS TRACTS -OP77ONAL SUPVISOR-DISTRICT CODE -OP770NAL <br /> o <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNL5pS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FONOaM17AR2 <br /> FORM A(9-90) — <br /> 1w a- <br />