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STATE OF CALIFORNIA ^``oVp e <br /> STATE WATER RESOURCES CONTROL BOARD 3 of <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �e <br /> COMPLETE THIS FORM FOR EACH F YISrrE ct"`°""'� <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM LV CL RE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> lJ SSO C` SUn S lD 5--v-0ADDRESS NEAREST CROSS STREET PARCEL#(OPFIONAQ <br /> �^ f7J/f,.Gl r <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> 11 BOX I <br /> TOINDICATE D CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY O COUIRYAGENCY <br /> O STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O1 GAS STATION ISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P,p. I.0.#(oplMnaq 3 FARM 4 PROCESSOR 0 RESERVATION <br /> 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 x WITH AREA CODE <br /> /" ! <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME C//JJ �� //O S CARE OF ADDRESS INFORMATION <br /> Wf]! S"p � SO n <br /> MAILING OR STREET ATE F <br /> ADDRESS(/ r:-, <br /> ✓ EoC bIMiCak INDIVIDUAL OCAL-AGENCY <br /> 17 ` 7 f` ` !�� O COUMVAGENCY_ CORPORATION 0 PARTNERSHIP 0 EERAGENCV <br /> l� FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S�o! [c�v1�, 7,0,7 �(6G�99y <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE.,ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa blMkela OINDIVIDUAL O LOCAL-AGENCY <br /> D STATE-AGENCY <br /> I�CORPORATION 0 PARTNERSHIP l�comy AGENCY 0 FEDERAL-AGENCYCITY NAME STATE ZIP CODE PHONE#WITHAREACODE <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: 1.0 II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANTS NAME(PRINTEDB SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 4 ,0 <br /> EEVF� C/4COs/`T <br /> LOCATIONCODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ^ <br /> 6 yD <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 /> FORMA(9-90) FORD <br /> 033A <br />