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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ye <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:-] 7 PERMANEy ED SRE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS CJ CO/0 PS P <br /> NEAREST CROSS STREET PAgCELa(OPFK1NAy <br /> z ter, 9 ,ick <br /> CITU NAME <br /> If STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> 1 r3 f A g BOX _ <br /> TOO INDICATE F,O PORATION O INDIVIDUAL (] PARTNERSHIP LOCAL-AGENCY ED COUNTY-AGENCY �� �! YzdS <br /> DISTRICTS O STATE-AGENCY (] FEDERAL-AGENCY <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0. <br /> I ;1(optional) <br /> O 3 FARM O d PROCESSOR HRESERVATON <br /> �� ER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FI 6T) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �` r o 2091-59 7-0 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> t <br /> MAILING OR STREET AD S ✓ bor blMicaN 0 INDIVIDUAL I1 LOCAL AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITU 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 ✓ bow Indicaw = INDIVIDUAL O LOCALAGENCY STATE-AGENCY <br /> CITY NAME - — D CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP LADE 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 F41 4 - D 8 y <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. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ffl�i OKLE3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> _7 <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) FGR0033A-R2 <br />