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Vn � <br /> STATE OF CALIFORNIA rnr 'cots <br /> i <br /> STATE WATER RESOURCES CONTROL BOARD � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Hanan M`n <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENTLY CLO <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PER 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACI ITY N E NAME OF OPERATOR <br /> tA� er �z� <br /> ADDRESS NE T SSTREET PARCEL#(OPTIONAL) <br /> 22 r IM Vt <br /> CITY NAME STATE ZIPDE SITE PHONE#WITH AREA CODE <br /> 21 1Y-VA CA,A Box <br /> �(S <br /> TOINDICATE IN CORPORATION O INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY D COUNTVAGENCY (] STATE-AGENCY O FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ) GAS STATION O 2 DISTRIBUTOR 0 RV IF INDIAN <br /> #OF TANKS AT SITE E.P. <br /> A.Y I.D.D.#y(OpI mep <br /> Q 3 FARM 0 4 PROCESSOR ® 5 OTHER OR TRUST LANDS Z CAD 98-L V71 OJ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAA{ 'NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> WArtne, t�[ 9 �4g - ( <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/) W4'e✓f S CARE OF ADDRESS INFORMATION <br /> MAILING ORSTFI V`ADDRESS G� ✓6^x b�NAM 0 INDIVIDUAL I1 LOCAL-AGENCY (�STATE-AGENCY <br /> 2 a CORPORATION O PARTNERSHIP Ij COUNTYAGENCY E-] FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA <br /> /CODE <br /> 2 <br /> L, �,rt16b ll 1�(O (71 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAM ;F OWN€R CARE OF ADDRESS INFORMATION <br /> 1p r wA}�4Pe.( <br /> MAILING <br /> /a OR STRE�ADDRE33 but InANN# � INDIVIDUAL � LOCAL-AGENCY Q STATEAGENCY <br /> Z717- Y (i( �l (Z CORPORATION O PARTNERSHIP COUNTVAGENCY FEDERAL-AGENCY <br /> CITY �A� ( STATEZIP r7 6( P <br /> IV.BOARD OF EQUALIZATION UST 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.O II.ISI III.O <br /> THIS FORM HAS BEEN COM ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> A PLInANr SNAME(PRINTED&SIGN I ` APPLICANTS`IRE � DATE � M ON�H��EAfl <br /> LOCAL AGENCY USE 0 Z <br /> COUNTY�# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> t' 3 <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 /> FORMAR2 <br /> FORM A(9-90) <br /> !r � <br />