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STATE OF CALIFORNIA `��� �'`„o�" •a°ct <br /> STATE WATER RESOURCES CONTROL BOARD 3 •- o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �. � '­! <br /> COMPLETE THIS FORM FOR EACH FAC <br /> MARK ONLY a 1 NEW PERMIT F-1 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM D 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE j a <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / <br /> DBA OR FACILITY NAME NAME OF OPERATOR a <br /> 7" v� ff-es <br /> G dvc <br /> ADDRESS NEAREST CROSS STREET PARCEL A(OPTIONAL) <br /> A- c��� <br /> CITY NAME STATE ZIP CODE SITE PHONE X WITH AREA CODE <br /> v BOX <br /> TO INDICTE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTORQ ✓ IF INDIAN ISOF TANKS AT SITE E.P.A. I.D.x(optional) <br /> IF <br /> Q 3 FARM Q 4 PROCESSOR c 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA�"E(LAST,FII�RST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NA (LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 4 J CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> HONE <br /> CITY NAME STATE ZIP CODE P 0 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 -1013 3 Ia a <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: 1. II.0 III.0 <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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 7i 't x,,4 Ql <br /> `l F77 I 1 1.20 � I �I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT♦ -OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> � i a3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> FORMA(490) <br /> 3 2 <br />