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�younces <br /> STATE OFCAUFORNIA :r ` <br /> STATE WATER RESOURCES CONTROL BOARD a` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "� <br /> C'X COMPLETE THIS FORM FOR EACH FACILrTYISITE °4pOe M� <br /> MARK ONLY F-1 I NEW PERMIT 0 3 RENEWAL PERMIT 0 a CHANGE OF INFORMATION EV 7 PERMANENTLY CLOS <br /> ONE ITEM F-1 2 INTERIM PERMIT Ej 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY E ^ r NAMEOFOPERATOR <br /> rn A/ ,fiVl <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> O `T ht)ro+tn <br /> CITYNAy7E STATER ZIP E Zo� SITE PHONE*WITH AREA CODE <br /> BOX <br /> 4TO INDICATE 0 CORPORATION [:1 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY 0 STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#IcpNanali <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR Q BOTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#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 /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boy bin#icah = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP WOE 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 V boa b Indica O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION Q PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CIN 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) HQ4 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: I.0 114:71 III.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 TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT/It # JURISDICTION# FACILITY# <br /> ® 700RAI 89- l91 <br /> LOCATION CODE - TIONAL CENSUS TRAC <br /> I# -OPTIONAL SUPVISOp-pISTRICT CODE -OPTIONAL <br /> d 23 . un J�'� I <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 /> FORMA(9-90) FOROMM-112 \ <br /> �I <br />