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STATE OF CALIFORNIA � �� <br /> 3 m o <br /> STATE WATER RESOURCES CONTROL BOARD W„� .��8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A f <br /> m . <br /> COMPLETE THIS FORM FOR EACH F LITYfSITE <br /> Q t NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION El7 PERMANENTLY CED SITE <br /> MARK ONLY <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE 8 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> I NAME OF OPERATOR <br /> arR �pNAM CD <br /> l + EA EST Cjh1OSS STREET PARCEL$(OPTIONAL) <br /> ADyBES� NlW VOi QSr+ <br /> 1951 j-0 n <br /> Ci M{� E STATE ZIP SITE PHONEDE <br /> �0(o >IWITz� CO <br /> CA C(�l <br /> 41e <br /> �L/IVY1l /v_L <br /> '/ soXCOpPORATION a INDIVID AL Q PMTNEflSHIP O LOCAL-AGENCY Q COUNTY-AGENCY O STATE.AGENCY 0 FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OFT TANKS AT SITE E.P.A. 1.0.#(oprbnap <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) <br /> =E;OD <br /> DAYS: NAME(LAST,FIRST) PHON #WITH AREA CODENIGHTS: NAME(LAST.FIRST) NIGHTS: NAM T.FIRST) PH #WITH AREA CODE <br /> \L <br /> C� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLi T D 'off <br /> N RE F ESS INFORMATION <br /> tD <br /> MAILING OR STREET ADDRESS ✓ box niMieau Q INDIVIDUAL L000.L-AGENCY Q STATE AGENCY <br /> 2� dmm04O✓� �CORPORATION = PAARRTNERSHIP O COUNTYAGENCY�/ � FEDERAL-AGENCY <br /> -ERRAL-AGENCY <br /> CITVME ���� ' STAT�� ZIV /_/ PHONE;f WITH AREA L�CD(��� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 1166AVV! <br /> NAMM/ Q 1710 <br /> v [�w CA✓RE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS b"bindkm INDIVIDUAL C::] LOCAL-AGENCY STATE-AGENCY <br /> � <br /> CORPORATION Q PARTNERSHIP COUNIYAGENCY 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 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. 111.7] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PRWTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# w'.7 JURISDICTION# FACIA <br /> 3l T� -fImr-:03o <br /> LOCATION CO)E -OPTIONAL CENSUS IKAC # -OPTIONAL SUPVLSO -DISTRICT CODE .OPTIONAL <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.A <br /> FORM A(990) <br />