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b°ua es <br /> STATE OF CALIFORNIA cy <br /> STATE WATER RESOURCES CONTROL BOARD t <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> (� COMPLETE THIS FORM FOR EACHFACILITYISTTE <br /> MARK ONLY L�l 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F--j 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Wh L5&4 <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 3 <br /> CITY NAME STATE ZIP DE SITE PHONE*WITH AREA CODE <br /> D/-/— CA j <br /> TOINDI ATE CORPORATION Q INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCY STATE AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN *OF TANKS AT SITE E.P.A. I.D.It(optional) <br /> O RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA COOS <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box bindimla =1 INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION l= PARTNERSHIP 0 COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �x blMkaU = INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 7 CORPORATION O PARTNERSHIP a COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY 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 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.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&SIGNATURE) APPLICANTS TIRE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# SHRKiB18T1911 #5tA�� FACILITY# <br /> an [LmEq 1WI1411 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 199 aff �?3,0U G-/7 ql <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(990) FOR0033A R2 r^\ <br /> v\ <br /> � r) A <br />