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'tyOUR G9 <br /> STATE OF CALIFORNIA J °: <br /> n STATE WATER RESOURCES CONTROL BOARD w a� <br /> (✓ RGROUND STORAGE TANK PERMIT APPLICAT - FORM A �e <br /> COMPLETE THIS FORM FOR EACH F /SITE °��,.o ,. <br /> MARK ONLY Q I NEW PERMIT 0 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F7 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE ,)a <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAORFACILITY NAME NAMEOFOPE OR <br /> e .Le r c c <br /> ADDRESS NEAREST CROSS STREET OF PARCEL 0(OPTIONAL) <br /> CITY NAME STATEZIP CODE SITE PHONES WITH AREA CODE <br /> c7n r CA <br /> Box <br /> TOINDICATE CORPORATION INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY (] STATE AGENCY Q FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOflO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.4(aprbn#) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /cCe4 tufo Geor _ QA - e.p7 <br /> NIGHTS. NAME(LAST,FIRST) PHDNE# AREACODE NIGHTS: NAME(LAST,FIR T) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / 0CARE OF ADDRESS INFORMATION <br /> R <br /> MAILING ORS ADDRESS ✓bDx bIn kab INDIVIDUAL LOCAL-AGENCY =1STATE-AGENCY <br /> CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> 5 c X309 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box bftWkNs 0INDIVIDUAL LOCAL-AGENCY El STATE-AGENCY <br /> E�]CORPORATION 0 PARTNERSHIP 0 COUNrY-AGENCY =FEWPAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 4 4 - D 3 a lP <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unlessor 11 s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.[71 H.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 a SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 111 7FI7 <br /> S <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> C) 3 3� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORMA(9-90) <br /> FOROM3AA2 <br />