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e5oua es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �.�� �s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT a 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SIE <br /> ONE ITEM = 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 0 CILITY N E NAME OF OPERATOR <br /> ADOFI NEAREST CROSS STR PARCEL#(OPTIONAL) <br /> Aa <br /> CITY NAME STATE ZIP CODE ,SITE PHONE#WITH AREA CODE <br /> ,5*1t/ ) ca /. gay y y- /3v� <br /> I/ BOX <br /> TO INDICATE RPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a I GAS STATION Q 2 DISTRIBUTORQ R✓ESERVATION <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> /g <br /> 3 FARM a 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> D YS: NA (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (Z101-0 iqq <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, ST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> do -/ <br /> MAILING OR STRE ADDRESS <br /> bo indicate Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> ORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY Yk"Y�'? 1Q/ <br /> CI 4t E STATE ZIP CODE _ °HONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N F OWNER 'ell / CARE OF ADDRESS INFORMATION <br /> MAILING O TREETDDRESS boete INDIVIDUAL <br /> QLOCAL-AGENCY STATE-AGENCY` _ ORATION <br /> Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> CA! C-/ 7&2- <br /> IV. <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4—F4]- <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.a 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 <br /> COUNT Y# ("&fitp� JURISDICTIIOON# FACILITY# <br /> F57 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL <br /> (�rJ3 G <br /> 3z/ <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 />