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'esoua es <br /> • STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> ^ 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e <br /> °4noe M`� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK\0V&/ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME /C/ll.E'/ {�Jy O//L O NAME OF OPF�fjATOR <br /> �$ .7 aTs GJ rI <br /> ADDRESS p 1 NEAREyR',0SS7REET Ste- PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP E SITE PHONE#WITH AREA CODE <br /> CAS36G 99a39/f <br /> ✓ BOX <br /> TO INDICATE O CORPORATION O INDIVIDUAL PARTNERSHIP 0 LO NCY Q COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTSTRICTSTRICTS <br /> TYPE OF BUSINESSGAS STATION O 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.%(optimal) <br /> RESERVATION 3 <br /> Q 3 FARM O 4 PROCESSOR O5 OTHER OR TRUST LANDS <br /> EMERGENCY WNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIR T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /�oSE�J ae .Po O 'S yDS ./�s u� X09•..599 - Ps <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 /> CARE OF ADDRESS INFORMATION <br /> E <br /> Zt1 <br /> MAILING OR STREET ADDRESS ✓ �xblMkab DIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> -;zz g S, *0 Y\. CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> OY-\— C� s 310 D 11 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> e.+r ON t <br /> MAILING OR STREET ADDRESS v bo bim t# D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> Q OV-T\N S W, S0 CORPORATION O PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ��11 STATE ZIP CODE PHONE WITH AREA CODE <br /> 03 113 — Ill I <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ <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 II.O III.Iv/ <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 15-11 92- A#7015e ZZ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> S -3 3 -zs-Sz <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 /> FORMA(9-90) <br />