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STATE OF CALIFORNIA ouR . of <br /> STATE WATER RESOURCES CONTROL BOARD ` '¢6 m• g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ; <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE c""°""�� <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT Ea 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> PI>✓ u Ou <br /> ADDRESS NEAREST CROSSSTREET PARCEL 9(OPTIONAL) <br /> Q SPd <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> >J CA <br /> TO INDICATE 11 CORPORATION INDIVIDUAL O PARTNERSHIP (]LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA GOD <br /> aoq- -631E DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 4 � CARE OF ADDRESS INFORMATI N <br /> Dom rwul�rmjm <br /> MAILIN OR STREET ADDRESS ✓ b##bl.. fO INDIVIDUAL E::] LOCALAGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUMY#GENCY (] FEDERAL-AGENCY <br /> CI 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 /> C_ <br /> MAILING OR STREI ADD S Eoc bYq = INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNrY-AGENCY O 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 [4p4 -� <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 H.pr 111.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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> K CIl� N 7� <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIOAML <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 /> FOR¢1 A(&90) p�\ FOR0093A A2 !, <br />