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STATE OF CALIFORNIA •���.� of <br /> STATE WATER RESOURCES CONTROL BOARD c <br /> C_.�NDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ro <br /> COMPLETE THIS FORM FOR EACH F LTTYISITE �•"'°""" <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT EEZ5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE S_-3 <br /> I. FACILITY/SITE INFORMATION 8t ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> •-�- <br /> ADDRESS <br /> �I NEAREST CROSS STREET PARCEIa(OPfxNlAU <br /> /d O-7 S. /y roc iv rc` <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA 000E <br /> S CA <br /> TO INDICATE ❑CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCALAGENCY <br /> 0 COUNTYAGENCY <br /> STATEAGENCY F<DERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 10-OF TANKS AT SITE E.P.A LD <br /> .a(cpArw) <br /> 3 FARM 4 PROCESSOR 5 OTHER ❑ TRUST L)TION <br /> ❑ 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 /> C Pi ✓u .209- Yb 6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• UST BE COMPLETED <br /> NAME C CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓Im III wdk Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> P Y O O 0 EZI CORPORATION Q PARTNERSHIP Q COUNTY 1GENOV FEDERAI#GENCY <br /> CIN NAME STATE ZIP CODE PHIXJE a WITH AREA CODE <br /> SLovlcFn� (315 9iZ0b-00d vis YG(, -31Lrr ;-- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sa •" Q t <br /> MAILING OR STREET ADDRESS ✓ Imr mmQ INDIVIDUAL ED LGCAL-AGFNCY Q STATE-AGENCY <br /> Cl CORPORATION PAITTNERS14P p COUNrY4GENCY p FEDEIML.AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 it questions arise. <br /> TY(TK) HQ 4 4 - p 3 a <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ 111.❑ <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 TIME DATE MONTRIDAYA'EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION t FACILITY 0 -1`3 CT rt o l <br /> LOCATIONOODE -OPTIONAL CENSUS TRACTS•OPT9D/YAL SUPVISOq-DISTRNCT CODE -OPTIONAL <br /> O/ a -'�,ice 3 2 3 <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(490) FORMA-12 <br />