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• oae <br /> STATE OF CALIFORNIA °o <br /> > <br /> STATE WATER RESOURCES CONTROL BOARD t4 m o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 5� <br /> COMPLETE THIS FORM FOR EAC FACILITYISITE <br /> MARK ONLY F-1 T NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE G <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OR FACIL e �rvc TY N NAME OF OPERATOR <br /> ana �: L� v I,�L - <br /> ADORE55��'-77 t71,)I �� NEAREST CROSS STREET PARURN(OPTIONAL) <br /> CITY N ME STATE ZIP COD�3 SITEP WITH AREA CO 7 <br /> 4h ro / <br /> TO INDICATE O CORPORATION l7:1 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTYAGENCY 0 STATE-AGENCY ' <br /> DISTRICTS O FEDERAL kGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#Txprwnal) <br /> RESERVATION <br /> Q 3 FARM = & PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CO E <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME_ CARE OF ADDRESS INFORMATION <br /> cd l7)o ncl <br /> MAILI�CJ�G OR STREELTL; DRESS ��O ✓ box bintlkate OINDIVIDUAL 0LOCAL-AGENCY 0 STATE- ENCY <br /> I C I I I X I �1� I�CORPORATION PARTNERSHIP Q COUNTY-AGENCY [=1 FEDERA AGENCY <br /> CITY MEST ZIP DE PHONE#WITH AREA CODE <br /> UA a F,, <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biMkau = INDIVIDUAL 0 LOCAL AGENCY 0 STATE-A ENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNrYAGENCY 0 FEDERA-AGENCY <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-F4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 hacked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: ❑� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT COPE -OPTIONAL <br /> O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR E PERMIT APPLICATION• FORM B,UNLESS THIS Is A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9-90) FCRW93A R2 <br />