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fssoua es co <br /> STATE OF CALIFORNIA � W <br /> STATE WATER RESOURCES CONTROL BOARD i -� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ye <br /> s,, o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT F� 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> rNT'S 2 <br /> ADDRESS NEAREST CROSS STREET PABCEIp(OPrgNAy <br /> 33/0 f- 144mlo 2 <br /> CITY NAME STATEZIP CODE SITE PHONE WITH AREA CODE <br /> Sta -M/,l _. C1 5 zo 4r&3 - 4`762 <br /> TOO IN ICBO TE O CORPORATION 2tINDIVIDUAL =PARTNERSHIP Q L�N-SENGY a COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO RESERVATION <br /> -/ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0,#(optional) <br /> 3 FARM 4 PROCESSOR E/ OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 0 Olt, GoA COO- <br /> MAILING OR STREET ADDRESS vbindvats O INDIVIDUAL O LOCAL-AGENCY = STATE-AGENCY <br /> Po_ CORPORATION = PARTNERSHIP =COUNrYAGENCY = FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> Sv25v�t <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> v f) lore P <br /> MAILING OR STREET ADDRESS ✓ box biMicam INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> p Q. &K ?-Vg CORPORATION PARTNERSHIP (] COUNTYAGEWY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE It WITH AREA CODE <br /> SvTsvi l pro (4 5 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -1 1 1 I—t—Lj <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.E H.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NANO(PR INTED B SIGNATURE) APPLICANT'S TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUMY# JURISDICTION# FACILITY# <br /> 316 101R 16 111'NETGb 3� <br /> LOCATION CODE OPTIONAL CENSUTOCT# -OPTIONAL B 'OR-DISTRICT CODE -OPTIONAL 4r r, <br /> �3a � <br /> THIS FORM MUST BE ACCOMPANIED BY ATLEAST(1)OR MORE PERMIT APPLICATION/•/FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOROW3AA2 <br /> FORM A(9-9O) \ <br /> /h V� <br /> J <br />