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,OUR ca <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ®� <br /> o;� <br /> �... <br /> l� COMPLETE THIS FORM FOR EACH FACILITYfSRE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATKN! O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE /J <br /> I. FACILITY/SITE INFORMATION It ADDRESS•(MUST BE COMPLETED) /C <br /> DBA OR FACILITY NAME NAME OF OPERATOR �,^`_ ' <br /> AD RESS N e 4 M P e /�KJL/�R� <br /> NEA ESTCROSS STREET PARCEL#(OPTIONAU <br /> / s <br /> CITY NAME STATE ZIP CODE SITE PLANE#WITH AREA OODE <br /> 4141hro CA <br /> ✓BOX <br /> TO INDICATE 5WIDDIRPDRATION O INDIVIDUAL 0 PARTHMSHP 0 LOCALLC�TS�Y COUNTY-AGENCY 0 STATEAGENCY (]FEDERAL-AGENCY <br /> DISTRITYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(apdvaW) <br /> Q 3 FARM Q 4 PROCESSOR 4�6 RESERVATION <br /> BOTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> -optional <br /> DAYS:NAME(LAST.FIRST) PHONE 8 WITH AREA CODE GAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME r�' CARE OF ADDRESS INF TION j <br /> D/V v L 6N PN� L.ci pt P/`) <br /> M IUNGP?STREET ADDRESS �j/� ✓(�ottb INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> / ♦ O. Ox .J-/D 0 COIIPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> Cc / O 5330 —0370 20 3—//(70 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> e <br /> MAILING OR STREET ADDRES Ooxb YIEIGI# 0 MVOUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERAL#GENCY <br /> CITY NAME STATE ZIP 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 F4]-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: 1.O 11.vr 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) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EL1 Z-A1/ <br /> LOCATION;00DEOPTIONAL CENSUSTRACT0 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2 3.8'0 32-5— V46/1?/ r <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 /> ORM A( FORWRMAR2 <br /> 490) <br /> 1 <br />