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IbbOVR f <br /> STATE OFCAUFORMA �• �o <br /> STATE WATER RESOURCES CONTROL BOARD A' 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�`� ae <br /> C��IIORR�I <br /> COMPLETE THIS FORM FOR EACH FA ILTTYISITE <br /> MARK ONLY 0 T NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 ERMANE� SED SITE , <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITVN M Q/ / �3 JnG NAME OF OPERATOR <br /> ADDRESS NEAREST CRO;VETO/ PARCELIImmU <br /> CITY NAME STATE/�•_X/ZIP CODE SITE PHONE s WITH AREA CODE <br /> o CA 95364C <br /> I/ BOX <br /> TOINDCATE [ 2T RPORATO! O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCY O STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O RESERVATII r OF TANKS AT SITE E.P.A. I.D.#(Sptlm•q <br /> Q ON <br /> 3 FARM Q 4 PROCESSORS OTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> oC� S 5 VI <br /> NIGHTS: NAME(LAST,F(RST) PHONEY WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> II. PROPE ER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMA N <br /> AILING OR STREET ADDRESS ✓Wa bintlkile INDIVIDU L LOCAL-AGENCY QSTATE-AGENCY <br /> CORPORATION Q PARTN IP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME t STa ZIP CODEC7d PHONE S WITH AREA CODE <br /> III. K OWNER INFORMATION• MUST BE COMPLETED <br /> NAME OF OW CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indica Q INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP E:D COUNTV#GENCY FEDERAL.IGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -W p g <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTCE <br /> ZIONAL NSUS TRACTS -OPTIONAL / SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 05 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 /> FOR0033A,R2 <br /> FORM A(9-90) <br />