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^�soun e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i4 b <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACiUTYIBrrE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 6 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME NA OFOPERATOR <br /> A DRESS — ^� NEAREST CROSS STRE PARCEL#(OPTIONAL) <br /> CITY I <br /> AME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> 6N CA QS'7 -S9 '? <br /> ✓ BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCALAGENCY Q COUNrYAGENCV 0 STATE-AGENCY 0 FEDERALAGENCY <br /> TO INDICATE <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTO O ,/ IF INDIAN N OF TANKS AT SITE E.P.A L D.N fopgmNQ <br /> RESERVATION <br /> = 3 FARM Q A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY OONTACr PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA DODENIGHTS: NAME(LAST,FIRS PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA <br /> W A tb'Ve- -&,0110 Grp 2 A 9 - (, _ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1�z+- T)i <br /> /- <br /> MATING OR STREET ADDRESS1 ✓ box blr&ab INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY <br /> — CORPORATION O PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CI NAME STATE CODE PHONE#WITH AREA CODE <br /> ✓ CIO -s - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ,, box bWinls O INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 2 rIJ J/�• 0 CORPORATION IO PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CgX <br /> :1 NEn6 CP �STA C/ V c - AEN W`9%d <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-25582 if questions arise. <br /> TY(TK) HQ 4 4 - S <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or if is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLIM NAME Sr"AlTURE) APPLIC STITLE 09 DATE MONTHIDAYNEAfl <br /> 4//Av/� — <br /> LOCAL AGENCY USE ONLY IF <br /> ®a JURISDICTION a FACILITY# <br /> ((JN?F 22- <br /> LOCATION CODE -t� �ONAL CENSUS TRACT# Z'IONALSUPVISR-DISTRITCODE -OPTIONAL <br /> 5 J J <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 /> L <br /> FORMA(9 90) FOHDMA-12 / <br /> .� �� i <br />