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a <br /> STATEOFCAUFORNASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AC., <br /> COMPLETE THIS FORM FOR EACH LTTYISITE <br /> MARK ONLY 0 i NEW PERMIT O 3 RENEWAL PERMITCHANGE OF INFORMATION V 7 PERMANENTLY CLOSED/gRE <br /> ONE REM D 2 INTERIM PERMIT Q d AMENDED PERMIT a TEMPORARY SITE CLOSURE V <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF ITYNAMOra-j <br /> E NAME OF OPERATOR <br /> h fY <br /> ADDRESS �• ^ NEAREST CROSS STREET PARCEL a(OPTpNAU <br /> CITY NAME/ STATE 7 CODE SITE PHONE 0 WITH AREA CODE <br /> CA <br /> v BOX <br /> T NpG1TE O CORPORATION O INDIVIDUAL E__1 PARTNERSHIP D LOCAL-AGENCY D COUNTY-AGENCY D STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A, I.D.a(nplAanal) <br /> RESERVATION <br /> 3 FARM O A PROCESSOR = 5 OTHER OR TRUST LANDS <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 a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST( PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD RESS ✓ boa bindkna =1 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY#GENCY E::] FEDERADAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS boa binEkals INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEMRAL.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ4 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.O II.O 111.a <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY /1�m,,Fl <br /> COUNTco <br /> Y a p JURISDICTION a FACILITY a <br /> MT h/oRri 15 Iy <br /> LOCATION CODE - TIONAL CENSUS TMCTs -OPTIONAL 3UPVISOR-DIST3�O 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 /> FCRON3AA2 <br /> FORMA(9-90) <br /> (�,N/ 1 <br />