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STATEOFCAUFORMA •O�" <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A " o <br /> CCOMPLETE THIS FORM FOR EAC FACILITYISrTE - °"•°^�o" <br /> MARK ONLY Q t NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> O T PERMANENTLY CLOSED SRE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 d AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION Il<ADDRESS-(MUST BE COMPLETED) <br /> DBA 2R,F-q{C-ILITYN 11 7 �i NAME OF OPERATOR <br /> / Qn/ )/'�Ic� GT�� ��/C( L <br /> ADDRESS1, <br /> NEARESTCROSS STREET PARCELS(OPTIONAL) <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE#WITH AREA CODE <br /> ✓ BOX CA <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL 0 PARTNERSMP 0 LOCAL-AGENCY <br /> DGTRIOTS O CWNTY#GENCY (] STATE-AGENCY 0 FEDERAL#GENCY <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR ✓ IF 11,111''1111s OF TANKS AT SITE E.P.A L O.s(aptimaq <br /> Q 3 FARM Q < PROCESSOR Q 5 OTHER OORRESERVATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(DZT,FIRST) PHONE S WITH AREA CODE <br /> II. PROPERTYOWNER INFORMATION• MUST BE COMPLETED <br /> NAME a ) _pe/d C* �( /hJ t �I ^ CARE OF ADDRESS INFORMATION <br /> MAILI ,STREET DRESS yrVI�i` till/�N�V (� EJ LOCALAGENCY 0 STATE-AGENCY <br /> DI M CORPORA ON Q PARTNERSHIP ED COUNIY#GENCY 0 FFDEML#GENCY <br /> CITY NAME STATE z7ulz PHONE a WITH AREA CODE <br /> 51W vx <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓IO.bwtl O IMXVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY#GENCY O FEDERAL-AGENCY <br /> CITY NAME STATE IIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -L ALJ <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' hecked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III.O <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) AFPLICANTS TITLE GATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT Y a JURISDICTION M FACILITY a <br /> m ORCc�v/o <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 A90) FORO=A-H2 <br /> V4ftr '"wo <br />