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STATEOFCALIFORNIA ^P�esooa e, ^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> ` UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH CILITYISITE <br /> MARK ONLY Q t NEW PERMIT 0 3 RENEWAL PERMIT <br /> ONE ITEM Z INTERIM PERMIT S NE 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> O 4 AMENDED PERMIT 0 B TEMPORApy SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> I W7 <br /> �/Y^ ('1 NAME OF OPERATOR <br /> ADORES 1 -W J 1 n ,.,/I ,v <br /> NEA TCROSS STRE <br /> PARCELp(OPTIONAy <br /> CITU NAME <br /> STATE CODE <br /> ✓ BOX G.A SITE PHO ;1 WITH AREA CODDEl� <br /> TO INDICATE 0 CORPORATION NDIVIDUAL 0 PARTNERSHIP �0 <br /> /—A? <br /> �+o <br /> LOCAL-AGENCY NCY (]COUNTY-AGENCY 0 STATE-AGENCY <br /> TYPE OF BUSINESS �( I GAS STATION DISTRICTS Cl FEDERAL-AGENCY <br /> =--^ Q 2 0157RIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P,A, I.D.M <br /> 0 3 FARM 0 4 PROCES30R 0 5 OTHER OOR RESERVAITRI IST 1 uN (00,QIW) <br /> EMERGENCY LONTACT P SON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> PHONE aWITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> P ONE N WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) <br /> PHONE•WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION A MUS BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ..0 ✓box b Indicate Q INDIVIDUAL <br /> CITY NAME j�(/ 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERSTATEAL-AGENCY <br /> STATE O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDEILALAGENCY <br /> ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEOFOWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> box It Indicate 0 INDIVIDUAL 0 LOCAL#GENCY <br /> CITU NAME CORPORATION DE 0 CDSTATE-AGENCY <br /> S TE PARTNERSHIP OUNTY#GENCY 0 FEDERAL-AGENCY <br /> ZIP CODE PHONE a WITH AREA CODE <br /> IV. B OF EQUALIZATION UST STORAGE FEE COUNT NUMBER- II(916) 739-2582 if questions arise. <br /> TY( K) HO <br /> V. LEG ESS 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 /> I.❑ II.❑ III.O <br /> TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE DATE <br /> MONTH/DAV/VEAq <br /> LOCAL AGENCY USE ONLY p <br /> couNrv# egRlu I E '�� <br /> T JURISDICTION# <br /> FAFACILITYI <br /> LOCATION CODE OPTIONAL CENSUS TRACT# OPTIONAL = 111ILITY#�y_ <br /> +, SUPVISOR-DISTRICT CODE -OPT/DNA( <br /> 3a� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INF_ Og[x1ATI0N ONLY. <br /> FORMA(9 90) <br /> l ' , <br /> • � �/ �r/� �_x FOR0053A-R2 <br />