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tf 0 R 2g <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3< o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A '�: <br /> a <br /> •°�(lFOP Nor. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Vf I NEW PERMIT F__] 3 RENEWAL PERMIT [_1 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT D 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) / <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 86P'6�Q C-4 P-5 SS)PTt o f"j Q rr9A M R 'tal4,,G®Q o(L CoM PA N <br /> ADDRESSNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ©t �1 TtlEAN -Kio.9 sc��TH LEE <br /> A��➢ a q-5 -130 - 1cI <br /> CITY NAME STATE ZIP CODE SITE PHON #WITH AREA CODE <br /> Lo oz Ca X75 U Czo9 3�v-�7�f� <br /> T NDIC TE LP-16RPORATION (] INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS [S2'0'1**GAS STATION 2 DISTRIBUTOR = <br /> ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(opficnal) <br /> RESERVATION <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) PH NE#WITH AREA CODE <br /> �f{ �R WAvg. L�9 S X33--33¢Z <br /> NIGHTS: NAME(LAST,FIRST) PHO E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �/ G 1•.1 _0q 5 -553 C�2 AUL Zcf� 3-3342 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> u P/\N <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> 0 INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> ORPORATION = PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#W TH AREA CODE <br /> i�ti1 GA �' o � 620q33¢ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> O U /J OIL y RT S <br /> MAILING OR STREET ADD ESS ✓box in indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Z a5_7 CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> H NN F�D(zD I CA 583-334- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4]-4]-1 11-11 <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.0 II.E] <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/DAY/YEAR <br /> �'e4 I�A� S_' " I <br /> LOCAL AGENCY USE ONLY 14 <br /> COUN7Y# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 7PVISOR•DISTRICT CODE -OPTIONAL <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 />