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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> LoNN, <br /> COMPLETE THIS FORM FOR EACHfiACIUTYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT R5,5 CHANGE OF INFORMATION 7 PERMANENTLY CD SRE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE v <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBAQR�ACIL TV NAME, NAME OF OPERATOR <br /> AOYfORJE ///ll v^'l'V�/T l'� , NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> vv• v��� — V <br /> CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> CA <br /> TO INDIIC TE D CORPORATION E:71 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#loptlmap <br /> RESERVATION <br /> O 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(L.AST,FIRST) C47NE a WITH AREA CO E DAYS: NAME(LAST,FIRST) PHONE M 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 /> NAAQ��D A� CARE OF ADDRESS INFORMATION <br /> I <br /> MAIL///NGJJOR TREET ADDRESS ✓ boa blrAkala UAL O LOCAL-AGENCY STATE-AGENCY <br /> (.fj, CORPORATION PARTNERSHIP Q COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NA STATE ZIP CODE HONE# HAREA CODE <br /> 00O,49 -7- <br /> Ill. <br /> 0O rIII. TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAM FOWNE CARE OF ADDRESS INFORMATION <br /> MAILING TREETADORES3 ox b bInakINDI <br /> au VIDUAL LOCAL-AGENCY I� STATE-AGENCY <br /> �' �� - (]CORPORATION O PARTNERSHIP I[D COUNrYAGENCY Q FEDERAL AGENCY <br /> CITU NAMEa� < STA E ZIP CODE HORNY# ITH AREA CODE <br /> IV. B!!OA_ F E <br /> RD OQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2562 if questions arise../ <br /> TY(TK) HO 4T_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.L�] 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEANDCbRRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANT'S TITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY qq f <br /> COUN^/# JURISDICTION# FACILITY <br /> I1 12 /`L'T�[J <br /> LOCgN CODE -OPTIONAL 7U$TRACT# -OPTIONAL 6530 STRICT 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 INFOR &TION ONLY. <br /> FORM A(39G) I///��� _ FOROW7Afl2 <br />