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•t6UUM G <br /> STATE OF CALIFORNIA . °s <br /> STATE WATER RESOURCES CONTROL BOARD sy g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> 0 <br /> COMPLETE THIS FORM FOR EACH CILITY/SfTE c•G�°O°G�• <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> / u .1 u 5><YiGs <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> Yoo S. �u/Jorc� <br /> CITY NAME STATE MP FOODE t WITH AREA CODE <br /> BOX �a CA q((n(o- 4r S/ <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAUAOEHCY 0 COUKryA ENCY 0 STATE4,GOICY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN Is OF TANKS AT SITE I E.P.A. L D.+(apt*W) <br /> 3 FARM d PROCESSOR E5 55 OTHER RESERVATION <br /> ❑ ❑ OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> u C n 707 '7/03-99// <br /> NIGHTS: NAIRE(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE s WITH AREA CODE <br /> II. PRO TY OWNER INFORMATION• MUST BE CO ETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 13 <br /> M ING OR STR T ADDRESS '7 b"00'*" 0 INDIVIDUAL 0 LOCAL AGENCY O STATE-AGENCY <br /> 3 C k C `u / 0 CORPORATION p PARTNERSHIP 0 OOUNTY-AGENCY O FEOETUL#GENCY <br /> CI NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �r.`Tcl�ti CA 1 9 4�-(0 3 7L� —x3—Y'y Yi <br /> III. TANK R INFORMATION•(MUST_BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Im Dmdim 0 INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O CGUNrY-AGENCY 0 FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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 - U Y Y <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: L E:] II.❑ III.❑ <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 B SIGNATURE) APPLICANTS TITLE DATE MONTHOAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 8E09ui- qo <br /> ffE 0 IEVI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIOWL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> of a3a-D 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(490) /N� � �42 <br />