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- 0 STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />•nnnree lint 10V DC/`nRADI CTrm <br />I. rMVI L1111 J11 <br />DBA OR FACILITY NAME <br />❑ 1 NEW PERMIT <br />❑ 3 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION ❑ <br />7 PERMANENTLY CLOSED <br />MARK ONLY <br />ONE ITEM <br />❑ 2 INTERIM PERMIT <br />❑ 4 AMENDED PERMIT <br />❑ 6 TEMPORARY SITE CLOSURE <br />t 6C_ � <br />'niCITY <br />•nnnree lint 10V DC/`nRADI CTrm <br />I. rMVI L1111 J11 <br />DBA OR FACILITY NAME <br />•• <br />,... <br />NAME OF OPERA OR <br />�r a �✓ic✓fc� <br />S y � <br />v� o <br />✓ bDa blydkaze D INDIVIDUAL <br />ADDRESS <br />t 6C_ � <br />'niCITY <br />0 CORPORATION 0 PARTNERSHIP <br />NEAREST CROSS ST ET PARCEL #(OPTIONAL) <br />CITY NAME <br />C E ZIP CODES <br />PHONE # WITH AREA CODE <br />STATE <br />ZIP?���� <br />SITE PHONE #WITH AREA CODE <br />I <br />O <br />CA <br />✓ BOX CORPORATION <br />D INDIVIDUAL O PARTNERSHIP D LOCAL -AGENCY 0 COUNTY -AGENCY STATE -AGENCY 0 FEDERALAGENCY <br />TOINDICATE <br />DISTRICTS <br />TYPE OF BUSINESS ❑ <br />I GAS STATION ❑ 2 DISTRIBUTOR/ <br />IF INDIAN ❑ RESERVATION <br />## OF TANKS AT SITE <br />E. P. A. 1. 0. # (aptimap <br />3 FARM <br />04 PROCESSOR HER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PH NE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE x WITH AREA CODE <br />cJ le'We- / i 20i 55 - 2 6 <br />NIGHTS: NAME (LAST, FIRST) FRIJINt a INI I H AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />it, rRVram I VYY <br />CARE OF ADDRESS INFORMATION <br />NAMEJ <br />MAILING ORSTREET ADDRESS /J <br />✓ bDa blydkaze D INDIVIDUAL <br />D LOCAL -AGENCY OSTATE-AGENCY <br />t 6C_ � <br />'niCITY <br />0 CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />NAME <br />C E ZIP CODES <br />PHONE # WITH AREA CODE <br />,42 4142-Y7 <br />TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ✓ bUbinEbale D INDIVIDUAL 0 LOCAL -AGENCY (] STATE -AGENCY <br />D CORPORATION D PARTNERSHIP 0 COUNTY -AGENCY D FEDERAL -AGENCY <br />CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER • Call (916) (J9-zbdz It questions arse. <br />TY (TK) HQ 44 - Z tj <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. ❑ II. �J 'll. ❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />I nrAI ArFNCV t1SF ONLY <br />C� JURISDICTION <br /># FACILITFTIZIY At � G 5L <�L! <br />LOCATION CODE -OPTIONAL CENSUS TRACT# Z TS 'Er 0 SUPVISODISTRICT a-6 CGDE -OPTIONAL J -l' 5- � I e—, <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 />Rz <br />FORMA (9-90) <br />i • Gj <br />