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eco�a es <br /> STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ;y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A s <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> o: .. <br /> MARK ONLY F--j T NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM F--j 2 INTERIM PERMIT E71 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NE ES CROSS STREET Pmvic (OFIONAL) <br /> CITU AME A—s Al- S CA ZBOX IP DE SITE PHONE S WITH AREA CODE <br /> s Q <br /> T NDICCATE CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY (] COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN It OF TANK$AT SITE E.P.A. I.D.#(apda1W) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION / <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST FIRST) PU2NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> b <br /> NIGHTS:NAME(LAST, RST) PHONE s WI H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILI R TFIfTOPRESS ✓box bWWW E-D INDIVIDUAL LOCAL AGENCY Q STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP D COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY AME STATE ZIP E PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED C <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V bob ir&b Q INDIVIDUAL E:3 LOCAL.AGENCY O STATE-AGENCY <br /> I=CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION <br /> �UST <br /> ,STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -L17J� LL.1.1 <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.O ILO III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PA INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY S B /yL <br /> COUNTY It JURISDICTION N FACILITY# <br /> 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPSUPVISOR-DISTRICT CODE -OPTIONAL <br /> a3lz <br /> 130101- <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) FOROW]A F2 <br />