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p;�ea`Rees <br /> STATE OF CALIFORNIA ? cA? <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 6ol <br /> c�4l6 pn N`� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CL D SIT <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE h1v/ <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME tt L NAME OF OPERATOR <br /> LCC �JCi'ir1PH S I'? !- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME !/ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> sirs 7'��q CA � YS33 6 2-3 <br /> ✓ BOX <br /> ORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY ® COUNTY-AGENCY I] STATE-AGENCY F71FEDERAL-AGENCYTO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(ophanal) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME( T,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE <br /> ^f <br /> NIGHTS: NAME(LASIRST) PHONE; WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> j g -z-3e <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 2ec •�ertnlvt r4 - <br /> MAILING OR STREET ADDRESS ��``��'� ✓ box to Indleate ® INDIVIDUAL I_I LOCAL-AGENCY STATE-AGENCY <br /> 3 17S f r�t'r�,CsC. 0 CORPORATION F__] PARTNERSHIP ] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMEA ,( � STATE ZIP C��lr`I PHONE A W6TH AREA CODE <br /> C/ E r <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS ✓ box bindicate © INDIVIDUAL LOCAL-AGENCY ® STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 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 [4 141- 0 1-z- 7 <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.0 it.L;�_ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# /`/d � <br /> 5T I C210 � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z 71� <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 /> FORA-R2 <br /> FORM A(9-90) <br />