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ti STATE OF CALIFORNIA J <br /> STATE WATER RESOURCES CONTROL BOARD i° - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A " ` "° <br /> L' N `. YI. o' <br /> / �4no. <br /> (/ COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Z 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS•(MUST BE COMPLETED) <br /> DSAOR fACI ITV NAME <br /> 0;yNAME OF OPERATOR <br /> /1 lflw4le—f� <br /> ADDRESS �� A"IL 100 /�.Y NE�RE$TCROfS 3TREI� ��jj�� PARCEL OPfpNAL)p <br /> CITY NAME STATE <br /> ZIP ��2 � (0093 3b8 I SITE PHI 4 WITH AREA 77 E <br /> `T <br /> Box <br /> TOINDICAIE O CORPORATION 0 INDIVIDUAL Q PARTNERSHIP 0 LOCALAGENCY Q COuNrY-AGENCY STATE-AGENCY (] FEDEMLAMNCY <br /> DISTRICTSTYPE OF BUSINESS T GAG STATIONQ 2 DISTRIBUTOR Q RESERVAINTI <br /> ION4 OF TANKS AT SITE E.P.A. L D.r/opimae <br /> a 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CO I DAYS: NAME(LAST,FIRST) P1+�NE 4 WITH AREA CODE <br /> ,b �91b) x,72!- Z <br /> NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 44vicro Di G. c:c, . <br /> MAILING OR STREET ADDRESS Ew bxgKllB O INDIVIDUAL O LOCALAGENCY 0 STATE-AGENCY <br /> -C/ ? j(� �(j/%�/00 CORPORATION C=j PARTNERSHIP O COUNTY-AGENCY ED FEDEMLAGENCY <br /> CIN NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> Go L,E � ov <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> O/e- 6119 <br /> MAILING OR STREET ADDRESS ,�✓ bei b'F4,US Q INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 'DCli/ /e ��. Svii4f iov L umWRATION O PARTNERSHIP O COUKrYAGENcY O FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE+WITH AREA CODE <br /> 4AS l 6 � 1 zvv—416 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <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.❑ it.❑ In.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPUCANPS NAME(PRINTED a SIGNATURE) APPLICANTS TIRE DATE MONTWDAYfYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# whvy� <br /> F45�fl 1/ 611 <br /> JV L <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 10 5a 300 <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 /> FOHD033AR2 <br /> FORM A(9-90) <br /> `� d!/ _ <br />