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�� • QSCURCPS <br /> STATEOFCALIFORNIA A r �•'� �o^ <br /> STATE WATER RESOURCES CONTROL BOARD r , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA o <br /> �. <br /> C�IIFOP N�' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE G <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL It(OPTIONAL) <br /> CIN NAME STATE A ZIP C G (SITE 3Z� 91 <br /> HrRD325w' <br /> ✓ BOX <br /> TO INDICATE CORPORATION ZfINDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS S STATION 2 DISTRIBUTOR R SEF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> EZ 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <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 /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LocAL.AGENCY STATE-AGENCY <br /> 7ee; f CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME/ STATE ZIP CODEHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> ,t/ ✓� 12 0 CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME /v STATE ZIP CODE ONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4T44]- <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.E] II.xr <br /> III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND ORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> _ FTMO I I �---- <br /> LOCATION CODE -OPTIONAL CENSUS TRA T#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �r <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 /> FOR0033A-R2 <br /> FORM A(9-90) �' <br />