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�¢OVR Cg <br /> STATE OF CAUFORMA �c~ '-••" °o <br /> STATE WATER RESOURCES CONTROL BOARD a` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM �� 00 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> / e, <br /> CITY NAME STATE ZIP CODE j ITE PHONE#WITH AREA CODE <br /> A <br /> f <br /> T DIC <br /> NTE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 I GAS STATION a 2 DISTRIBUTOR ® RESERVAD�®N #OF TAN SAT SITE E.P.A. 1.D.#(optional) <br /> 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST, IRST) /Z HON`� <br /> NH REA COD DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) \ PHOJE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> - f Q CORPORATION Q PARTNERSHIP Y-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE#WITH AREA CODE <br /> 4, ed '7 7 <br /> III. TANKOWNER INFORMATION-( UST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V box IDindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> - 0- 1 Q CORPORATION Q PARTNERSHIP NTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE / PHONE#WITH AREACODES <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(T ) - <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <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 MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COON-e Y# JURISDICTION# FACILITY# <br /> 3 � 10161111 !g <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 1 <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 <br /> L <br />