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• STATE OFCAUFORNA • °pOo"o;'co <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A v o <br /> C. h . <br /> COMPLETE THIS FORM FOR EACH FACILRYISRE <br /> MARK ONLY T NEW PERMIT ❑ 3 RENEWAL PERMIT E::] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAME OF OPERATOR <br /> O nJ Q <br /> 6 <br /> ADDRESS NEAREST CROSS STREET PARCEU IOPTIONAp <br /> e <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> BOX <br /> S7 � CA <br /> TO NNC TE CORPORATION INDIVIDUAL [::] PARTNERSHIP 0 LOCAL-AGENCY ED COUNTY-AGENCY <br /> DISTRICTS STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O ) GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN r OF TANKS AT SITE E.P.A. L D.#(apliarel) <br /> 3 FARM 4 PROCESSOR = 5 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 s WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Wic... L_j INDIVIDUAL E::] LOCAI.AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP GLIDE 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 ✓ box 0micalc INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ED CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q 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 F4—F4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank 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.O II.O III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE M0NTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> F31T FACILITY# <br /> ® IWRTK,76 <br /> LOCATION CODE -OPTIONAL CENSUSTRACT#•OPTIONAL SUPVISOR•DISTRICT CODE -OPT/ONAL <br /> 9 3 .80 2 C <br /> THIS FORM MUST BE ACCOMPANED BY AT AST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9.90 , \ <br /> f" O�\ � FIXio037AR2 �� <br />