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STATE OFCAUFORMA a <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM AC COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT LYJ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q d AMENDED PERMIT Q B TEMPORARY SITE CLOSURE 63 <br /> I. FACILITYISITE INFORMATION&ADDRESS e(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 1 a/J Orn <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTOMU <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> N4ecC CA 9533-6 ;zBox _ 3 _ <br /> TO INDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP ED LOCAL-AGENCY ED couNTY-AGENCY 0 STATEA)MICY l3 FEDEMLAGENCY <br /> DSTPICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR I ✓ IF INDIAN 18 OF TANKS AT SITE E.P.A. L 0.#(twi W) <br /> RESERVATION <br /> Q 3 FARM Q { PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AS ( _ - G,l ,A, C / Za9 - 3- OS <br /> NIGHTS: NAME(LT,FIRST) PHONE#WITH AREA CODE NIGHTS: AME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> KS ti riS_e <br /> MAILING OR STREET ADDRESS ✓batind1cm [1)INDIVIDUAL 11 LOCAL-AGENCY 0 STATE-AGENCY <br /> Qd Q I O CORPORATION =PARTNERSHIP I1 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#WITH AREA CODE <br /> RL oN rfl <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER CARE OF ADDRESS INFO RMATKON <br /> S06"e as <br /> MAILING OR STREET ADDRESS but Wkwo Q INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> O CORPORATION 11 PARTNERSHIP O COUNTY#GENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE J WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HO T74 -� <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.ur II.Q 111.FD <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED a SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> = C'As rc �s 0 s s <br /> LOCATION CODE -OPTpNAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> as 1 23 3z5 3/zz/97 e{� <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 /> FORM A(490) FOROGMA-R2 ^ <br />