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GoUR <br /> STATE OF CALIFORNIA � .P <br /> STATE WATER RESOURCES CONTROL BOARD s` o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y; <br /> `1 <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OR <br /> FOPERAT <br /> �' � r/o1� ���e <br /> ADDRESS ,, / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH A EADE <br /> BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> IF <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS —�� <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 /> �`' nl� f t i ,) � 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AR A CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> `' •• Wit) 3 --Z-moi 3 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> 1 ."e 01 lGlIc 2�5Af J =CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NA/ME STATE ZIP CODE_ fgqHONE WITHARE COD <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �cAh E 4_ rev - <br /> MAILING OR STREET ADDRESS <br /> ✓box ID Inch a INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE �L !� PHONE#WITH AREA CODE <br /> /,- 4:154 <br /> 4:1 ` 7/ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4_1_41- <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. II. 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# S / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> U - �Zv <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 /> ` <br /> FORM A(9-90) FOR00.73A-R2 <br /> At/ <br /> * il� <br />