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STATE OF CALIFORNIA <br /> i STATE WATER RESOURCES CONTROL BOARD s ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE <br /> MARK ONLY I NEW PERMIT O O RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PE ENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q l AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> _ tl� <br /> ADDRESS NEAREST CROSS STREET PARCELi(OPTIDNAU <br /> So32 S F/ sfi <br /> CITY NAME STATE ZI CODE SITE PHONE#WITH AREA CODE <br /> S CA b <br /> v BOX <br /> TOINDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCA)-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY <br /> DISTR <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IS OF TANKS AT SITE E.P.A L D.*(apimw) <br /> RESERVATION <br /> Q S FARM Q i PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> 'YeMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> / DAYS:NAME(LAST,FIRST) PHONE i WITH AREA 000 DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> 1 NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREOFADDRESS INFORMATION <br /> Q$ <br /> MAILING OR STREET ADDRESS ✓ box bkdoib [D INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O COUNNAGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> PW If PC A7 017 <br /> MAIL GOO STREET ADDRESS �i ✓EN bYMlti11 INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> Q_ 66 0 CORPORATION 0 PARTNERSHIP (] COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME SJI�;� ZIP CODE PHONE#WITH AREA CODE <br /> ��e�ltrl.nl 4 O <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HQ F4-F4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Iorllischecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.a 11.Q 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 a SIGNATURE) APPLICANTS TITLE DATE MONTHAOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> a I BULkT30 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> •9-0 <br /> THIS FORM MUST�-ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (� <br /> FOROWUA2 <br /> M <br />