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ft„OV„ fS <br /> STATEOFCAUFORMA ^f ?, <br /> STATE WATER RESOURCES CONTROL BOARD p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A L� y <br /> COMPLETE THIS FORM FOR EACH F LITYISITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SrTE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE Ow <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME G I NAME OF OPERATOR <br /> _S-0s <br /> ADDRE NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> S, Avir a r a <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c A- CA 95-,2,041 - of, Ybb Yl <br /> V BOX <br /> TO INDICATE 0 CORPORATION INDIVIDUAL =PARTNERSHIP (]LOCAL-AGENCY (] COUNTY-AGENCY 0 STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ' <br /> IF INDIAANN #OF TANKSAl) <br /> 7AT SITE E.P.A. L D.#tgWm <br /> AT <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS J <br /> EMER NCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a v c e, 13e -707 - 7G3-S9 // <br /> NIGHTS: NAME(LAS'(,FIRSPHONE 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 /> -16"e i_h.1Gi n :;e s <br /> MAILING O TREET ADDRESS // ✓ wxmmN m = INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> S/7 6--)4 5 '. 4' CORPORATION Q PARTNERSHIP ]COUNTY#GENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PTH AREA CODE <br /> HIXNE#WI <br /> - fly <br /> 707 <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS laxbWkae Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> Sk Lt (]CORPORATION D PARTNERSHIP O COUNNAGENCY O FEDERALAGENCY <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 - 0 3 <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 11. III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY Olo <br /> COUNTY# JURISDICTION# �., FACILITY# 6,cAv�-y 0 <br /> ® L—l_L-LL-L0 1/ Ve I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTDEDE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIOWNLY. <br /> FORWJ3AA2 <br /> FORM A(490) <br /> *ft.-, <br />