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'tbpUa f <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> G COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-� i NEW PERMIT O 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE Ty <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADD ESS NEAREST CROSS STREET ARCEL#(OFnDNAL) <br /> X00 s. oruc% 54 <br /> CITY NAME STATE ZI OODE SITE PHONE 0 WITH AREA CODE <br /> 7r6A am CA 5'23/ 67- 3 - R-9-2r. <br /> BOX TOINDICATE 0 cOnPORATKIN Q INDMDUAL I=PARTNERSHIP Q LOCAL-AGENCY 0 COUNfY#GENCV 0ST <br /> ATE-AGENCY (] FFDEPAL#GENCV <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION 0 2 DISTRIBUTOR RESERVATION <br /> VIF INDIAN <br /> *OF TANKS AT SITE E.P.A. I.D.0(tpI/mN) <br /> Q 3 FARM O 6 PROCESSOR O 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(UST.FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> ala � Y_ r"ee" ze(o klai✓ <br /> MAILING OR STREET ADDRESS VbDX 0in&M INDIVIDUAL E:1 LOCAL-AGENCY STATE-AGENCY <br /> , D X 976 0 CORPORATION (] PARTNERSHIP COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE a WITH AREA CODE <br /> Hu5ko j G4 s3 i6 2e9-Srs-3 -Zcyz <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> e - As- <br /> MAILING ORSTREET ADDRESS V bDX bindiuta E--1INDIVIDUALLOCAL AGENCY 0STATE-AGENCY <br /> I=CORPORATION l= PARTNERSHIP 0 COUNTY-AGENCY I= FEDERAL-AGENCY <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 I-� <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.v 11.O III.O <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 B SIGNATURE) APPLICANTSTITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® ©a*kp 9z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -6P77ONAL <br /> 97 Z3-so 3 zr 3/z'>/9z H <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 /> FORMMA2 <br /> FORM A(9-90) <br /> 7' � <br />