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-�yauacE <br /> STATE OFCALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> OaN <br /> COMPLETE THIS FORM FOR EACH FACILRYISRE ll(l <br /> MARK ONLY D T NEW PERMIT F7 3 RENEWAL PERMIT5 CHANGE OF INFORMATION �RMAN NTLV CLOSE <br /> DIVE REM 2 INTERIM PERMIT 0 d AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILfTY1SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROW STREETn �j PARCEL#(OPTIONAL) <br /> 2 yV tC le ZI a4 /<o <br /> CITY NAME STATE ZIP CODE <br /> 5 36 G SITE PHONE#WITH AREA CODE <br /> R,4 e``7 CA <br /> TO/ BOXTE O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY (] COUNTY-AGENCY 11 STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 T GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.#(gX/mW) <br /> ION <br /> FARESERVAT <br /> RM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME( T,FIRn PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �?e <br /> MAILING OR STREET ADD SS ✓ box b Mica 0 INDIVIDUAL I1 LOCAL-AGENCY E:3 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY [::] FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE/WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> five <br /> MAILING OR STREET ADDRESS box Wndt a I1 INDIVIDUAL O LOCAL AGENCY 0 STATEAGENCY <br /> D CORPORATION O PARTNERSHIP OOUNTYAGENCY FEDERAL-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 - C)3 -Z- 2 <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.1 I-L:1 III.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(PR INTED&SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# &4LC0 7-3 <br /> y37 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <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 /> F\'ORJ0033AA2 <br /> FORM A(&90) <br /> V <br />