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ouR .s o <br /> • STATE OF CALIFORNIA is <br /> ^+ ? <br /> STATE WATER RESOURCES CONTROL BOARD w� ,�m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ye <br /> it 41fO,IN�N <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME` NAME OF OPERATOR <br /> RESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ADDY000 0 <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREAC E <br /> Gni ca f-1 'zI/ BOX <br /> �0 <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP O LOCAL AGENCY O COUNTYAGENCY D STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 r GAS STATION 2 DISTRIBUTOR RE/ IF INDIIAN ON #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> a,) <br /> FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE%WITH AREACQDE / DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /4G F12 <br /> L/ . �?///J��#/.51 <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 STREETADDRESS ✓ box bindkab DIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> 0� F— I,�CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> Clry NAM0L STATE- ZIP Z-W& HONE#WITH AREA COD <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) `/'/Y� <br /> NAME OF OWNER AI / CARE OF ADDRESS INFORMATION <br /> _ '%11-N <br /> MAILING 09 REET ADDRESS ✓ bUbindb#% Q INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CI NAME I ZIP C055 J.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 4 4 -� <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: <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/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRT# OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Y /y <br /> 2 Z tJ a <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(390) FIIIA-12 <br />