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eeoua es <br /> STATE OF CALIFORNIA Ar r '°--•- °o <br /> STATE WATER RESOURCES CONTROL BOARD = <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A iA�': <br /> COMPLETE THIS FORM FOR EACH F LITYISfTEF_ <br /> MARK ONLY D 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL S ITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 9� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) v <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /- <br /> ADDRESS NEAREST CROSS STRE& V PARCELIN(OPTIONAL) <br /> 1711 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> IV14--7 CA y 209 - 2 - <br /> TO DIC TE Q CORPO TION Q INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE D:FI:3USINESS [Vr 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Gamss- a - sAr0%-d- <br /> NIGHTS: NAME(LA,%;r,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 50/n4e S'4� � <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1-4 R Cv /Jura le'?^-- <br /> MAILING OR STREET ADDRESS S ✓ box to Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> /� 1 l CARE OF ADDRESS INFORMATION <br /> gecv <br /> MAILINGRSTREET�DRESS n ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> /"i O, /jam X L� Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE#WITH AREA CODE <br /> 9 V y . <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4U4 - <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.a II.a 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 39 16 -o I Z I v jjrj 31 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2 3 X 1 3 2,G <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 /> FORM A(9-90) FOR0033A-R2 X <br />