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Is STATE OF CALIFORNIA • a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SRE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT <br /> 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> 9 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITYNAME� / NAME OF OPERATOR <br /> ADDRESS <br /> 72GVi)l.nlu// <br /> NEAREST CROSS STREET PARCEL#(OPn0NAq <br /> �j-.z�0✓E <br /> CITU NAME <br /> STATE ZIP CODE z <br /> 11 eox CA SITE PHONE,WITH AREA CODE <br /> 9` �� <br /> TOINDICATE CORPORATION INDIVIDUAL (__1 PARTNERSHIP Q LOCAL AGENCY E-1 COUNTY-AGENCY Q STATEAGENCY 0 FEDERAL-AGENCY <br /> DISTRICTSTYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR r� ✓ IF INDIAN #OF TANKS AT SITE E.P. i I.D.#(optionelJ <br /> 0 3 FARM O 4 PROCESSOR u 5 OTHER O RESERVATION <br /> 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 /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> QG� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Intllcala <br /> �Q' O INDIVIDUAL f�LOCAL-AGENCY (]STATE-AGENCY <br /> CITY NAM =CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP E- "!;I"./ PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAIL�JG OR STREET ADDRESS ✓ box b IMkale <br /> = INDIVIDUAL = LOCAL AGENCY QSTATE-AGENCY <br /> CITU NAME l� CORPORATION Q PARTNERSHIP = COUNTY.AGENCY FEDERALAGENCY <br /> �A�- STATE 21P('A) PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-22582 if questions arise. <br /> TY(TK) HQ 44 -� <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 /> lO 11 ❑ III O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, <br /> IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE <br /> DATE MONTHIDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> C�FODU 17YY�# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# OPTIONAL SUPVISOR-DIBTRICT LADE -OIT7PT/ONAL <br /> ??J 1-77 <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(9-90) <br /> FOR0033A-H2 <br />