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°o.•... <br /> ..." STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °•��•°"� <br /> MARK ONLY O I NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> ONE REM a 2 INTERIM PERMIT Q d AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> v <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSAFACT ITV N E NAME Of OPERATOR <br /> tc� e r e�,( <br /> ADDRESS NE TCFCISS STREET VC PARCEL#(OPTIONALI <br /> "22 E FpUr <br /> CITY NAME STATE ZIP 9POE SITE PHONE g WITH AREA CODE <br /> 121 *'ZA CA S <br /> TO INDICATE ®CORPORATION Q INDIVIDUAL Q PARTWjmP Q LOM-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR RE/ IF INDIIAN ON A OF TANKS AT SITE E.P.A I.D.S lcptbl ) <br /> Q 3 FARM Q A PROCESSOR ® 5 OTHER OR TRUST LANDS Z IfAD 'UL 1171 &5'76 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA NAME(LAST,FIRST)Ik <br /> PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE <br /> AV-Ke m[ ?meq S4g- ! I <br /> NIGHTS: NAME(LAST,FIRS PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME n '.-•�n✓� ( CARE OF ADDRESS INFORMATION <br /> MAILING OR SSVT`R?AAOORESS _ ^ ✓ m#0� Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 2 {r��1�1I U/1 (3'(/ CR CORPORATION Q PARTNERSHIP Q COUMYAGENCY Q FEDERKAGENCY <br /> CITY NAME STA ZIP CODE PHONE#WITH AREA CODE <br /> CX- ���6b SCI-61771 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM/�F OW.*€ ' CARE OF ADDRESS INFORMATION <br /> 1p rwt}�4 �2�( <br /> MAILING OR STR,ADDRESINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ` ECY -AGENCY CY117, 5ZCORPORATION PARTNERSHIP COUNrYAG <br /> CITY N E STATE ZIP CODE P E g WITH AREA CODE <br /> t"Z I C r,,, l0'1 &i4 ( 721 <br /> IV.BOARD OF EQUALIZATION LIST 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.ISI 111. <br /> THIS FORM HAS BEEN COM D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> A L NAMEM C(PRI`OED 8 SIGN V�L L �Y APPLICANTS TITLE y DATE � MON WDAYNEAR <br /> � <br /> LOCAL AGENCY USE 0 /thl — 2 S <br /> CpUNT'y g JUN g FACILITY At I <br /> Lf 201 <br /> LOCATION CODE -OP7'ML CENSUS TRACTa -OPTIONAL —75R-DISTRICT CODE -OPTIONAL �7 <br /> II 3I <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 /> FORMOAF2 <br /> FORM A(S-W) <br />