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• oun es <br /> STATE OF CALIFORNIA We ci <br /> STATE WATER RESOURCES CONTROL BOARD A' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� y; <br /> o � . o <br /> �i <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °��,.o .� <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT [7j5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME / NAME OF OPERATOR <br /> G ✓FiiF� � E{ <br /> —//P .G <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> 6vAA&A ;- e,- we_ o f — 2Dc - o <br /> CITY NAME STATE ZIP CODE I SITE PHONE#WITH AREA CODE <br /> ,2�J Tb�I CA <br /> v BOX <br /> TO INDICATE I7]CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY E�71 COUNTY-AGENCY STATE-AGENCY 1:1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 ) GAS STATION 0 2 DISTRIBUTOR0 ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.N(aptlm#I) <br /> RESERVATION Z— <br /> Q 3 FARM 4 PROCESSOR f- 5 OTHER 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 _ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bm b101bala D INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY AGENCY E-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP C , PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> E-4 <br /> MAILING OR STREET ADDRESS/ _ bUbinEkau INDIVIDUAL E-1 LOCAL-AGENCY ESTATE-AGENCY <br /> 0' - CORPORATION Q PARTNERSHIP [-I COUNTY-AGENCY [�:] FEDERAL-AGENCY <br /> CITU 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) HQ [4 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: I.❑ II.T III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COU�NT/# JURISDICTION# F�A�CIILITTYY## <br /> Z <br /> LOCATION CODE -OPTIONAL DENS STRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF srrE INFORMATION ONLY. <br /> FORM A(8.90) FORW]9R2 <br />