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�`eyO�a es c. <br /> c s <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY LJ I NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1TE�� <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OF OPER OR DRAORFACILI NAME I fes e- <br /> ✓G r NEARES7C OSSS BEET PARCEL#(OPTIONAL) <br /> ADD ESS � n <br /> .S 'L-J - r� , .�. <br /> STATE ZIP CODE TE PHONE#I WITH AREA CODE <br /> CITY NAME CA S 3 3 d Zd <br /> G, � <br /> � <br /> C}ATE COR ATSON INDIVIDUAL � PARTNERSHIP f� LOCAL-AGENCY � COUNTY•AGENCY [�STATE-AGENCY []FEDERAL-AGENCY <br /> TOINDI <br /> ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.0(Optima!) <br /> TYpE OF BUSINESS 1 GAS STATION E:] 2 DISTRIBUTOR RESERVATION <br /> 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHTS: <br /> S: NA E(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE A WITH AREA CGDE <br /> O / / � PHONE#�WITH AREA CODE <br /> NAME(LAS ,FIRST► PH NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS17 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE ADDRESS INFORMATION <br /> NAME <br /> ,/box oa iodic INDIVIDUAL ® LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADESS <br /> t}(�) i RPORATIDN I� PARTNERSHIP 0 COUNTY-AGENCY � FEDERAL-AGENCY <br /> STATFn ZIP CDD: PRONE#WITH AREA CODE <br /> CITY NAME I i} <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> e s_ � <br /> ✓ bex r inkaw (] INDIVIDUAL LOCAL AGENCY pSTATE-AGENCY <br /> MAILING OR STREET ADD SS <br /> []CORPORATION (] PARTNERSHIP COUNTY-AGENCY pFEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#z WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 2 �} <br /> V. LEGAL NOTIF ATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICAT1NG ICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[-] II.= III.= <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ,,7777::!!�:�rPFL71CANWPS <br /> TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY U <br /> COUNTY# JURISDICTION# FACILITY# �E / <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> LOCATION CODE -OPTIONALCENSUS TRACT* -OPTIONAL —21 � 7 <br /> 015 Z 'Yo f <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST{t}OR MORE PERMIT APPLICATION FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 R0033ARP <br /> i <br /> FORM A(9-90) II' <br />