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STATE OF CALIFORNIA �^ <br /> STATE WATER RESOURCES CONTROL BOARD s' �4 _ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A "m� �e <br /> /J 1wuw M�^ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY OI NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 1 2 INTERIM PERMIT Q A AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> L SaV (rJ 'I r, r <br /> ADD ESS NEAREST CROSS STREET PARCEL91OPrIONAL) <br /> 9;Z00 S. EI Da oto S <br /> CITY NAME STATE LP CODE SITE PHONE i WITH AREA CODE <br /> MOLL rrer3clv, Qcvov CA 7523 1 1207- s- z6 <br /> TOI/ BOX IN GTE O CORPORATION �INgVWAL l�PARTNERSHIP 0 LOCAL-AGENCYD0 COUNfYAGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS Q ( GAS STATION 0 2 DISTRIBUTOR0 ✓ IF INDIAN i OF TANKS AT SITE E.P.A. L D.i(00alap <br /> RESERVATION <br /> 0 3 FARM Q A PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> i ti a 63 z6 K N -883 -9 <br /> NIGHTS: NAME(LAST,FIRST PHONE t WITH AREA CODE NIGHTS:NAME(LAST,FIRST PHONE i WITH AREA CODE <br /> I rJ — —70-5 0 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Zek <br /> as <br /> MAILING OR STREET ADDRESS ✓ boa Io Nk" 0 INDIVIDUAL 0 LOCAL AGENCY 0 STATE AGENCY <br /> 0 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATF, ZIP CODE PHONE i WITH AREA CODE <br /> 11 C 115326 207- -2 2. <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED F OWNER �) CAREOFADDRESS INFORMATION <br /> U S / <br /> MAILING OR STREET ADDRESS ✓ box 104MkW 0 INDIVIDUAL 0 LOCALAGERCY 0 STATE-AGENCY <br /> O CORPORATION 0 PARTIERSMP 0 couNTY.AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F41-4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank nUnles x r 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. IN.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY f ,IS TRUE A CORRECT <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE MONTFVDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION t FACILITY t <br /> Im It 6 (/gcKP7;- <br /> LOCATIONCA -OPTIONAL CENSUSTRACTO -OPTTOMAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> -3 .go as- '11719t C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> FORM A(&IO) <br /> FORMA R2 <br />