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STATE OF CAUFORNA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION ° FORM A <br />COMPLETE THIS FORM FOR Feces Fenl m,crrc <br />MART( ONLY <br />❑ 1 NEW PERMIT <br />3 RENEWAL PERMIT <br />t�lS CHANGE OF INFORMATION O <br />7 PERMANENTLY CLOSED SITE <br />ONE REM <br />2 INTERIM PERMIT <br />O 4 AMENDED PERMIT <br />a S TEMPORARY SITE CLOSURE <br />f <br />�S-+ / <br />I. FACILITY/SITE INFORMATION 3 ADDRESS - (MUST RE CnMpi FTFm <br />DBA OR F9CIUTY NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />NAME OF OPERATOR <br />CITY NAME <br />ADDRESS <br />ZIP CODE <br />PHONE i WITH AREA CODE <br />EST CROSS STREET <br />PARCEL#(OFT"AL) <br />c <br />_, <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE 4 WITH AREA CODE <br />CA <br />BOX <br />TO INDICATE <br />Q CORPORATION <br />Q INDIVIDUAL Q PARTNERSHIP <br />Q WCALAOENCY Q COUNTYAGENCY <br />Q STATE -AGENCY Q FEDERIL.AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />O T GAS STATION Q 2 DISTRIBUTOR' <br />IF INDIAN <br />OORRR <br />4 OF TANKS AT SITE <br />E. P.A. L D. # (aprwW) <br />0 3 FARM <br />O 4 PROCESSOR Q S OTHER <br />9RVLAION <br />FYFHUrNGT CUNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE 4 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 P WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETFDI <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />OM ohhAM Q INDIVIDUAL Q LOGALMIENCY Q STATE AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COWM44ENCY Q FEDERALAGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE i WITH AREA CODE <br />III. TANK OWNER INFORMATION -(MUST BE COMPLETED) <br />NAME OF OWNER CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ,/ W.tlm.m Q INIXYDIAL Q LOCALAGENCY Q STATE -AGENCY <br />CORNRATION Q PARTNERSHIP Q COURNAGENCY Q FEDE(ULAGENOY <br />CITY NAME STATE I ZIP CODE PHONE 4 WITH AREA CODE <br />IV. t5UAHD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 it questions arise. <br />TY (TK) HO F4—F4]- <br />V. <br />4 -V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: La ILO III. F--] <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 a SIGNATURE) APPLICANTS TITLE DATE MONTH/GAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUN_. Y# JURISDICTIONS FACILITY III <br />ffl� FFT] 15 N Lf 15 11 ac t <br />1%3 /y;�- <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 (9901 <br />fORONM417 <br />