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,OUR z <br /> STATE OF CALIFORNIA wf <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Q o <br /> COMPLETE THIS FORM FOR EA FACILITYISTTE <br /> MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IV5 CHANGE OF INFORMATION 7 PERMANENTLY/CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE M D <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 4J <br /> DBOR FACILITY NAM NAME OF OPERATOR <br /> AVA 1d '', R V'� CoF.,,IrTER -+. I' &_r-T-ON - U N t rED 5TATus I VA Y <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 300 M04TE 1DlAaLo 47Nve T 5 <br /> CITY NAME STATE ZIP ODE ITE PHONE#WITH AREA CODE <br /> 51 TG�KTDM ca G`d 3I/ BOX <br /> apt 9y4 -C� <br /> TOINDICATE D CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCYU(J FEDERAL•AGENCY <br /> DISTRICTS /` <br /> TYPE OF BUSINESS 0 I GAS STATION 2 DISTRIBUTOR RESERVATION <br /> A #OF TANKS AT SITE ��yqE.P.A. I.D.#(Wibnal) <br /> 3 FARM 4 PROCESSOR 5 OTHERFOR TRUST LANDS IC-AC 00058 gr52 L) <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM AST,FIRST) P ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST} PHONE#WITH AREA CODE <br /> Lf-NAW <br /> ETTON �� y- 0516- <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> "ON1Tep �5TATE5 KAVY <br /> MAILING OR STREET AD KESS ✓ box b indicate � INDIVIDUAL <br /> • d`� (] LOCAL-AGENCY � STATE-AGENCY <br /> 3 ` N -DIAGLO AVC-tJ V G 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY5EOC K T U N STAjF ZIP CODE 5 2 0 z©9)ONE 4s I WITH <br /> qq_ 0515 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERaa /�� / _ CARE OF ADDRESS INFORMATION <br /> 5A M U- A5 h�=a[JY E <br /> MAILlNGORSTREET ADDRESS ✓ box mindicate <br /> INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> CORPORATION E__1 PARTNERSHIP © COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)739-2682 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 x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IE.[7] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# r <br /> r LJ 12k <br /> LOCATION CODE -OPTIONAL C NSUIS TRACT# -OPTIONAL SUPVtSOR-DISTRICT CODE -OPTIONAL <br /> ( r �3 . Z- 5 (Gfgr1 Pv� <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(9-46) <br /> FOR0033A-R2 <br />