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c oun es <br /> STATE OF CALIFORNIA z c w <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� ys <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> °•��.u.w� <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR ,. <br /> OA/lVPrsa.l >�i/rsl� aa✓acfS 08 5/"j elm <br /> ADDRESS NEAREST CROSS STREET vPARCELI(OPrIONAL) <br /> ssy S 6'I orctclo <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> do CA Q5ZL6 <br /> T Np TE o CORPORATION o INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY o COUNtVAGENCY o STATE.AGENCY o FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(goNarW) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> SfN ekrL J fxe Zoq- 2,5— <br /> NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G�Nt✓ COm N <br /> MAILING OR STREET ADDRESS ✓ box blNb = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> STS d CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> Mod e5-> G; 19s3so <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 66v1eP d �alucfs <br /> MAI INGOB STREET ADDRESS boxbbMka# = INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> D. 3/46190 O CORPORATION =PARTNERSHIP O COUNrY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP OODE PHONE#WITH AREA CODE <br /> 154 5-713 -- 6 v <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 44 - Q 7A 6 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LO II.O 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(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION♦ FACILITY# <br /> LOCATONCODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRKiT CODE -OPTOAIAL <br /> 01 23. 60 3�S— 3 Q� c <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 R2 <br />