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�gOURCes <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •C,�lRON NSP <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F__j 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM =] 2 INTERIM PERMIT = 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE d <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME A� NAME OFOPERATOR(' f� <br /> �tII i r Y•lC,r )L 17 ! iT i ® fie <br /> ADDRESS L NEAREST CROSS STREET PARCEL#(OPTIO L) <br /> 9 mot I VI <br /> CITY NAME A STA ZIP COAD ® S2® E# AREA CODE <br /> A <br /> TOINDCATE [?!rbRPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY ®COUNTY-AGENCY STATE-AGENCY J� FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optimal) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST(FI T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADD ESS INFORMATION <br /> MAILING OR STREET DRESS ^y ✓ IoxIDindicate 0 INDIVIDUAL (� LOCAL-AGENCY STATE-AGENCY <br /> Z <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP PHONE#WITH AREA CODE <br /> AL5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bOx b Indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4-F4 _ o 0 R] <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.F_j It. <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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o-9-- ZS 2.6 <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) d�- FOR0033A-R2 <br /> /I `.IeMC <br /> tri `T o f 4 ®t <br />