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t�,OU <br />STATE OF CALIFORNIA • �: <br />STATE WATER RESOURCES CONTROL BOARD 3 , <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A mom' <br />O I <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 0 I NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 PERM ENTLY CLOSED <br />ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE ) O <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY N <br />E <br />O'd <br />NIGHT :NAME (LAST, FIRS PHONE # WITH AREA CODE <br />NAME OF OPERATOR f <br />J(L,441)� <br />V box bind tate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />nom( Ja��son <br />ADDRESS <br />✓ box b Indicate Q INDIVIDUAL <br />QLOCAL-AGENCY <br />NEARESTCROSS TREET <br />PARCEL #(OPT <br />Q CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY <br />Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />CITY NAME <br />/ <br />PHONE # WITH AREA CODE <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />o7- <br />L`Z - o o <br />CA�� <br />f'5-5 <br />5 � - m zs' <br />BOX <br />TO INDICATE <br />CORPORATION Q INDIVIDUAL Q PARTNERSHIP <br />Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />STATION 0 2 DISTRIBUTORQ <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATIONINDIAN <br />�L�J <br />3 FARM O 4 PROCESSOR Q 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />(LAST, IRST) PHONE # WITH AREA CODE <br />DAYS: Z/r/1 ! e -e 707 - <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHT :NAME (LAST, FIRS PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />It. PROPERTY OWNER INFORMATION - (MUST RE COMPLETED) <br />NAME <br />ow <br />CARE OF ADDRESS INFORMATION <br />4 �s <br />J(L,441)� <br />V box bind tate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />MAILING ORREE ADD SS <br />✓ box b Indicate Q INDIVIDUAL <br />QLOCAL-AGENCY <br />QSTATE-AGENCY <br />2 <br />Q CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY <br />Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />o7- <br />L`Z - o o <br />III- TANK OWNER INFORMATION - (MUST RE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />4 �s <br />MAILING OR STREET ADDRESS <br />V box bind tate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE ___[PHONE <br />#WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (TK) HQ [4T-4] - G <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. III. 0 <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 # ,elhlO 6 ( Q <br />t <br />LOCATION CODE -OP 1 74 CENSUS TRACT # - OPTIONAL 7-6SUPVISOR - 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 />FORMA (9-90) <br />FOR0033A-R2 <br />