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STATEOFCAUFORMA •�6a� s <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILfTYISRE <br /> MARK ONLY Q 1 NEW PERMIT F7 ] RENEWAL PERMIT 5 CHANGE OF INFORMATION E:1 7 PERM Y CLOSED 9ffE <br /> ONE REM [::] 2 INTERIM PERMIT Q A AMENDED PER 8 TEMPORARY SITE CLOSURE j <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> m Gh TJA N <br /> ADORE srcRROSS STREET PARCEL a(OFONAL) <br /> 0 370�� D <br /> C da V_ -- - - STA ZIP CODE <br /> -oCA SITE PHONE s WITH AREA CODE <br /> � h g'S7�j <br /> BO <br /> TO DICCAATE Q CORPORATION Q WDIYWAL Q PARTNERSHIP [M�rM]GI CY Q COUNTYAGENCY Q STATE-AGENCY <br /> Q FmERAL.AGENcr <br /> CTS <br /> I <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR O RESERVATION✓ IF INDIAN s OF TANKS AT SITE E.P.A. L D.X 6mom ) <br /> n <br /> Q 7 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS �— <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE P WITR AREA COOS NIGHTS:NAME(LAST.FIRST) PHONE I WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Jo LeADuh <br /> MAILING OR STREET ADDRESSSLL [� ✓ Goa biIINGM Q INDIVIDUAL Q LOCAUAGENCY Q STATE-AGENCY <br /> / NON N7UJ1 7a'Ya 77� LT T/ ' Q CORPORATION Q PARTNERS14P Q COUNNAGENCY Q FEDERAL.AGENCY <br /> CIN NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CAPE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS boabodiNM Q INWYOUAL Q LOCAL-AGENCY Q STATE-AGFHCY <br /> Q RPORATION Q PMRNEASMP Q COUNTY-AGENCY Q FEDEML#GENCY <br /> CITY NAME STATE ZIP CODE PHONE I 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 - 0 3 (o <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner un s w oh ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLWG: L IL IN. <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 i SIGNATURE) APPLICANT'S TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY s JURISDICTION t FACILITY a $%EF7,4HT I 1 1110 <br /> S E <br /> LOCATION CODE •OPTXNALICENSU9 TMCT11- TgNAL 9UPVISOR-DISTRICT COOS -OP7lOWµ <br /> V Z 3iJ CO <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFSTrE.IN4MATION ONLY. <br /> FORM A(9-913) Fogoovpa2 <br />