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60JA p <br /> 44W STATE OF CALIFORNIA Nwe << i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A ?� a <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> SITE <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> 11 DBA OR FACILITY NAME NAME OF OPERATOR <br /> r <br /> NE RESTCROSS FEET. PARCEL#(OFTIONAU <br /> ADDRESS -`2 <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> LO <br /> '/ Box CORPORATION Q INDIVIDUAL Q PARTNERSHP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERAL <br /> #GENCV <br /> TOIND LATE DISTRICTS <br /> TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN N OF TAN AT SITE E.P.A. I.D.#(apHarwl) <br /> RESERVATION (/ <br /> Q 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> F <br /> S: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE <br /> TS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR31) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `� bDK 0 IM� Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bmwlM Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A 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 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN^Y# JURISDICTION# FACILITY# f <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRK:T CODE -OPTIONAL <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 /> FORM3AA2 <br /> FORM A(9-90) <br /> �'`Q (A1 <br />