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STATE OFCALIFORMA ;-� �? <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� �° <br /> v; <br /> COMPLETE THIS FORM FOR EACH FA ISITE <br /> MARK ONLY Q H NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLgSgp SrrE <br /> ONE ITEM 0 2 INTERIM PERMIT d AMENDED PERMIT E:] S TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA 0 R FACILITY NAME NAME OF OPERATOR <br /> n r f/, ,� - / /�cv�s-z- <br /> ADDRESS NEARES ROSSS7REET PARCELI(OPTIONAU <br /> CO CJS N. ce, lArd, -, a t <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> v BOX CA 1 9S-1) -fa <br /> TO INDICATE ED MVVUAL O PARTNERSHIP Wc aENCY O COUKTYAGENCY Q STATE-AGENCY Q FEDEMLAGENCY <br /> RICTS <br /> TYPE OF BUSINESS O GAS STATION Q 2 DISTRIBUTORQ -/ IF INDIAN IN OF TANKS AT SITE E.P.A. L D.#(oplimW <br /> OR <br /> RESERVATION 0 <br /> O 3 FARM Q A PROCESSOR 0 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 7] <br /> NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> u Sa <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bkul"M E:) INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP Q COUNTYAGENCY C3 FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH C <br /> AREA CODE <br /> AREA <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bmbMbW ED INDIVIDUAL ED LOCALAGENCY 0 STATE-AGENCY <br /> CORPORATION ED PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIPCODE 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 F4]-4]-LJ—LIJ <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box LW II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III.O <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTXONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a38a 3a� <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 /> �A) �0 9_q ��� <br />