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a�zoua ex <br /> STATE OF CALIFORNIA . �. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> VVV UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A `� <br /> COMPLETE THIS FORM FOR EACH t5COCITYISITE <br /> MARK ONLY Q 1 NEW PERMIT ❑ 7 RENEWAL PERMIT 10'5 CHANGE OF INFORMATION 7 PER SITE <br /> ONE REM 2 INTERIM <br /> 2ITEIM PERMIT _ TEMPORARY SITE CLOSURE <br /> I. FACIL E INFORMATION&ADDRESS-(MUST BE COMPLETED) ` <br /> OBAORF 17NAME - NAME OF OPERATOR <br /> of`I y _ <br /> ADOR S NEAREST CROSS STREETCEL$(OWIONAU <br /> CITY NA E <br /> STATE ZIP CODE 9' ,SZv) SI PHONE$WITH AREA CODE <br /> J —36 — <br /> ✓ 90X CORRMA Q INDIVIDUAL O PARTNERSHIP ED LOCAL-AGENCY iGENCY <br /> TO IN 1= STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS a I GAS ST TION 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE <br /> RESERVATION <br /> Q D FARM D A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE$WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE$WITH AREA CODE <br /> N A� µJe4 7i - 3 I -9 y 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 NTH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - nn /` CARE OFA ADDRESS INFORMATIONAV O <br /> / e'-eT l0 t G!! vrP.Jno vl-7G� �fJnC Pr <br /> MAILING OR STREET ADDRESS ✓ Oo[o'ukioM [:1 INDIVIDUAL C3LOCAL-AGENCYQ STATE-AGENCY <br /> (� o x Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEE) ML-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE$WITH AREA CODE <br /> /Qtve�s c(Q Cfl °7 1?S6S7 7/L/- 36y-7o5-0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CAPE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS INDNIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> p CORPORATION Q PARTNERSHIP p COUNTY-AGENCY Q FEDERAL-AGENCY <br /> STAT <br /> CITY NAME E MP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO F4-[-4]- <br /> V. LEGAL NOTIFICATION A 40 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.a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANPS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHN)AYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# SV N R 1 qS <br /> m I ! 308 <br /> LOCATION CODE -OPTIONALCENSUS TRACT# -OPTAONAL SUPVLSOR-DISTRICT CODE -OPTIONAL <br /> 01 <br /> �3� 3a.a (ok, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3W) FOROPJTAA2 <br /> z�6'1 '� <br />