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g60V" td <br /> STATE OFCALIFORNIA • - `� <br /> STATE WATER RESOURCES CONTROL BOARD _ o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> G #' <br /> COMPLETE THIS FORM FOR EACH CILITYISRE <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOS <br /> ONE ITEM F7 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED <br /> DBAORFACI ITYNAME A OFOPERATOR <br /> ADDRESS /< <br /> S_TR <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 3 "f— <br /> ✓ Boz <br /> TOINDICATE CORPoflATION (]INDIVIDUAL (]PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDI #OFT KS AT SI E.P.A. I.D.#(optimal) <br /> RESERVATI <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUSTE 5 <br /> j - EMERGENCY CONTACT PERSON (PRIMARY) RGENCY CONTACT PERSON (SECONDARY)•optional <br /> / DAYS: NA E(LAST=NIGHTS: NAME(JAST, <br /> F ST) PH NE#WITH AREA CODE DA S: AME(LAST FIS HON # ITH AREA CODE <br /> a - Cao 3�Y- G <br /> IRS P NE#WITH AREA CODE NIG S: NAME(LAST,FIRS PHONE# ITH AREA DECvrr`e/ <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓boa In Indicate INDIVIDUAL 0LOCAL-AGENCY (]STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP COUNTY-AGENCY (] FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabindbtl# 0 INDIVIDUAL (] LOCAL-AGENCY O STATE AGENCY <br /> (]CORPORATION PARTNERSHIP (] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. B����ACCOUNT NUMBER-Call(916)739 2582 if questions arise. <br /> V. LEGAL��DRESS 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 I.O 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV 57 <br /> LOCAL AGENCY USE ONLY <br /> C�OOU�NT'YY# JURISDICTION# FACIE <br /> . L'�-/� <br /> LOCATIONCODE -^OPTIONAL CENSUS TRACT# -OPTED AL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> CY\ 3 a <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(9.90) QAC//J FORDW3A R2 <br />