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STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD 3� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> .. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �����`•. <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION I!1 ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S CA gs'zo� <br /> TOINDICATE O CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCALAGENCY COUNTYAGENCY O STATE AGENCY O FEDERMAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 T GAS STATION Q 2 DISTRIBUTOR RESERVATION # TANKS AT SITE E.P.A. L D.#(aplbwp <br /> 0 3 FARM O 4 PROCESSOR O 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 /> MAILING ORS REETADDRESS t V boxbindb O INDIVIDUAL LOCAL-AGENCY STATEAGENCY <br /> Gr S Lt =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERMAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> L—D i gS ZY� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS boa0 Wicale INDIVIDUAL LOCAL-AGENCY STATEAGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTYAGENCY FEDERAL-AGENCY <br /> CRY NAME STATE 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 44 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E—) II. III.O <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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY � <br /> COUNTY# JURISDICTION# FACILITY# Sk /7 <br /> EET �/ <br /> LOCATION CODE -OPTbNAL CENSUS TRACT# -OPTIONAL SUPVISOq-DISTRICT CODE -OPTIONAL <br /> 0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(490) <br /> '7 <br /> A412 <br />