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ssoua <s <br /> STATE OF CALIFORNIA �a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �4,roNN✓ <br /> COMPLETE THIS FORM FOR EACH FACILITYISR E <br /> MARK ONLY � NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SIE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE OZ <br /> rssue oZ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> IDDS <br /> CILITYN E NAME OF OPERATOR <br /> I a if �( �� NE4R�STORR IS STREY-T PARCEL%(OPTIONAL) <br /> CITYN STATE/ldY4Zl OD / SITE PHONE*WITH AREA CODE <br /> CA R/'J <br /> BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL = PARTNERSHIP DSTRICTSENCY O COUNTY-AGENCY (] STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O ( GAS STATION 2 DISTRIBUTOR RESERVATION OF <br /> TAN/KJS AT SITE E.P.A. I.D.#(oplianel) <br /> Q 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS [1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> F7;; <br /> PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CT) PHONE%WITH AREACOOE NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ 6oxblMkate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP E-1 COUNN AGENCY FEDERAL-AGENCY <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 bmbbEk%b INDIVIOUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP E::] COUNTY-AGENCY FEDERAL-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 K41- � <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: 1.0 IL O 111.O <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PFI INTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# ,� JURISDICTION# FACILITY# <br /> LOCATION CODE -OP IONAL CENSUSTRACT# -PT NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE-AST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> /FCAOIXi9Afl2 <br /> FORMA(9-90) /l/ <br />