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"�pOUP GS <br /> STATE OFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD °G t o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y g <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE " °"O'°""" <br /> MARK ONLY E:1 ) NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 02 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE C <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ✓ <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ewnl �" a /ON <br /> ADDRESS NEAREST CROSS STREET PARCEL#IOPTIONAy <br /> 500 SR <br /> CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> ✓ eDx <br /> ZO-Y6E 29 <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL I= PARTNERSHIP D LOCAL-AGENCY COUNTYAGENCY STATE-AGENCY I11 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ) GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OFT KS AT SITE E.P.A. I.D.S(oPNmeq <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDSer <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE S 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 - ✓ hoxmlAUmab ED INDIVIDUAL OLOCAL-AGENCY EJ STATE AGENCY <br /> CITU NAME <br /> _ _ _ I]CORPORATION =1 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY� 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 boa"'WkAW = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> _ _ CORPORATION ED PARTNERSHIP = COUNTYAGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONES WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ r4-T4]- <br /> V. <br /> 4 -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. II.O III. <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ❑� ( 2 CAAv7-E/5� <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT S -OP77ONAL SUPVISOR-DISTRICT CODE -OP770NAL <br /> C71 23. 80 <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 /> FORM A(9-90) FORD033A-R2 <br />