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U,`01/ "you. e <br /> STATE OF CALIFORNIA ,. "" <br /> STATE WATER RESOURCES CONTROL BOARD s' 9 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� v; <br /> .„ o <br /> COMPLETE THIS FORM FOR EACH FAKaaa <br /> �����`• <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHFORMATION 'r7!�!7i-puWFNTLY CLOSED SITE <br /> ONE ITEM r--j 2 INTERIM PERMIT Q 4 AMENDED PERMIT 06 TE RARY SITE CLOSURE- - <br /> f,PR 18 1991 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPEERATONVIRONMENTAL I'IEALIH <br /> ADDRESS I NEAREST CROSSS PARCEL*(OWIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA q 3 <br /> TO.1 BOX <br /> INDICATE CORPORATION INDIVIDUAL I] PARTNERSHIP a LOCAL-AGSENCY D COUNTYAGENCY .STATE-AGENCY O FEDERILAGENCY <br /> DISTRICT <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTflIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION 7— <br /> EMERGENCY <br /> J <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS L <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 /> i <br /> NIG TS: NA (LAS T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE <br /> S - 9 ilz <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Jo 5�1 oL I <br /> AILING OR STREEINDIVIDUAL O LOCAL-AGENCY {STATE-AGENCY <br /> L.OK-ic'u- CORPORATION PARTNERSHIP COUNTY AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> O PHONE#WITH AREA CODE <br /> eac CAs�7G <br /> Ill. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> AMEOFOWNER_0(or VTNpk4I ['TAd.lA� <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OOOR STREET ADDRESS �bl�� (] INDIVIDUAL 1� LOCAL-AGENCY TATE-AGENCY <br /> L'o '� CORPORATION Q PARTNERSHIP O COUNIYAGENCY = FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> TF-Acq CA I <br /> et <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 44 -1 1 1 [_]= <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.0 II.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(PRINT 8S NA RE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> S-vbi4d <br /> (57F-0jeaoeo a <br /> LOCAL AGENCY USE ONLY <br /> COUMY# JURISDICTION# FACILITY# <br /> ® t / <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISO -DISTRICT CODE -OPTIONAL <br /> 0; 2� ,116 G /2S <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 /> FORM3A R2 <br /> FORM A(9-90) <br /> I <br /> I/ <br />