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• �SOURCe4 <br /> STATE OF CALIFORNIA AP" Co <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A00 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT P5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Q Wt G3 v �G "(wCS <br /> ADDRESS'M � I N NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATEZIP CODE ITE PHONE#WITH AREA CODE <br /> M� cg CA S '33, <br /> BOX <br /> TNDICATE ff7mMRPORATION F__1 INDIVIDUAL E�j PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR / IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION L <br /> 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: AME(LAST, IRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1� cs -Z C9 <br /> NIGHTS: NAME(LAST,FIRST) PHefNE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �;C/iS G d v L <br /> MAILI G OR STRE T ADDRESS ✓ box lo indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> z A/0. r ORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAMESTATZIP CODE ONEITH AREA C <br /> „ S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> -JCC, <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 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 4 -10 6 (, 3 <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 it.E] 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY /� Q <br /> COUNTY# JURISDICTION# FACILITY# 80KI 10 i fa <br /> t�l &E?Vl <br /> LOCATION CODE -�ONAL CENSUS TRACT# -OPTIONAL � SUPVISOR-DISTRICT CODE -OPTIONAL ��^ ^ � _ ^ <br /> Z 6 '( CA. <br /> THIS <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 /> FOR0033A-R2 <br /> FORM A(9.90) Al <br />