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'Gy�UR t$ <br /> STATE OF CALIFORNIA `D s <br /> STATE WATER RESOURCES CONTROL BOARD � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA0,11 <br /> I� <br /> • Ci ClrOM1 N,,r <br /> COMPLETE THIS FORM FOR EACH FACILITYISlTE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA CR FACILITY NAME NAME OF OPERATOR <br /> cHinuA Lo <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> car i <br /> CITY NAME STATEZIPcc <br /> dE SITE P� 1 WITH AREA <br /> CA S I �(n <br /> TO DICATE D CORPORAT10N (] INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY `[] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 RESERVINDIAN ATION s OF TANKS AT SITE E.P.A. L D.X(ppfiona!) <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS; NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE R WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> c <br /> MAILING OR STREET ADDRESS box to indicateINDIVIDUAL <br /> `� ED LOCAL-AGENCY Q STATE-AGENCY <br /> 1 a (_]CORPORATION = PARTNERSHIP COUNTY-AGENCY Q FEDER4L-AGENCY <br /> CITY NAME STA J� ZIP CODE <br /> c� PHONE#WITH AREA CODE <br /> l �J�C) HK <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD KESS ✓ box IDindicate © INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ( b Q Q CORPORATION 25-PARTNERSHIP 0 COUNTY•AGENCY 0 FFOERAL.AGENCY <br /> CITY NAME STATE ZIP CODE ONE X WITH AREA CODE <br /> P <br /> q 5203 s q 3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ f_4__F4 -1 1 LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or II is checked. <br /> F HECK <br /> NE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.I� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 4.SIGNATURE) APPLICANTS TITLE DATE MONTH+DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CO�J# JURISDICTION# Z�j FACILITY# w C,vf Pumr_t,}D, <br /> f1 LOCATION CGDE -OPTIONAL C�ti US TRACT:M,•OPTIONAL S� ISOR-DISTRICT CODE -OPTIONAL �I }N 1n P <br /> -218 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF srrE INFORMATION ONLY. +� <br /> FORM A(9-90) \ <br /> FOR0033A-82 \ <br />