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oua e <br /> STATE OF CALIFORNIAc <br /> STATE WATER RESOURCES CONTROL BOARD 14 ec ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A " � ve <br /> o. ;.. <br /> COMPLETE THIS FORM FOR EACH FACILfTYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O S CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE (J <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A RESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> 20 AvE 11 WO 1 V_w <br /> CITY NAME STATE ZIP CODE FITE PV NE s WITH AREA CODE <br /> z'f LT CA <br /> TOINDICATE O CORPORATION INDIVIDUAL i1 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR E RESEIFF INDIAN x OF TAN AT SITE E.P.A. L D.a(OPU MO <br /> 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE s WITHAREA CODE DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> 5 0 /G q� �3/- <br /> NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baa okdkal° INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> / l CORPORATION PARTNERSHIP Q COUNTY-AGENCY I1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PIONE a WITH AREA CODE <br /> 61v GAa �2 D � 3'31' 7/7 <br /> III. TANKOWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> AILING OR STREET ADDRESS �✓ bOlbI1NICWa D INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION I1 PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NA E STATE ZIP CODEPHONE i WITH AREA CODE <br /> 2 l <br /> IV.BOARD OF EQUALIZAA�TIOON�UST ST�ORAG�E FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO <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.a II. 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 a SIGNATURE) APPLICANTS TITLE DATE MONTKDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION NI FACILITY 0 <br /> ® ba©1TSy <br /> LOCATION CODE -OPTIONAL CENSUS TRACTO -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o Z 1 y3. 3TC 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 /> FORMA(9-90) <br /> FO1=3A R2 <br /> A/ <br />