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STATEOFCAUFORNIA `i <br /> STATE WATER RESOURCES CONTROL BOARD i� - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A :"� =e <br /> COMPLETE THIS FORM FOR EACH FACILTTY/SrTE �•��•°�.• <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT [:J�CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 GG <br /> 2 INTERIM PERMIT O 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE ! / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> W I L L `o yj 14 TD 2 C LV/n/ E MC 0O w6L/- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3600 C. scgLo.v A✓- T C44i.,2 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 4EsC-AC0/ / tom . CA s-g-2.0 2a9- 003ip- 3935 <br /> v Box <br /> TO INDICATE D CORPORATION [%NDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DSTRCTS <br /> TYPE OF BUSINESS c/f I GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.x(aptkna) <br /> RESERVATO <br /> 1TS� <br /> Q 3 FARM O 4 PROCESSOR Q 6 OTHER ORTRUSTLANDS <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 /> 11 CAOM/cLL ELV.,.v 2a _ 7.3Q-3g3.1- FalL959 JeRRYW4?- 3 - 351;2 <br /> NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> .2#9- " 3 ?- 74-// 1 baa -.2"6 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> cGvim c. M Co0bve'eL <br /> MAILING OR STREET ADDRESS ✓Ear b lr&b <br /> �INDIV6IUAL � RACAL-AGENCY �STATE-AGENCY <br /> 1,5&0 5 C/a LCORPORATION E-1 PARTNERSHIP (]COUNTY#GENCY [-3 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> L�Se Loi✓ C q aj5 3.� 09- pr4?- 3f&2- <br /> 111. <br /> 932III. TANK OWNER INFORMATION• MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 61V/n/ E. /0c40d4✓tLL <br /> MAILING OR�STREET ADDRESS �y OovbWbAa INDIVIDUAL E-1LOCAL-AGENCY STATE4MICY <br /> 1-?605 eA9 e� i F• O CORPORATION 0 PARTNERSHIP (] COUNTYAGENCY FEDENALAGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ESC,q LonJ 34R0 3932 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 P4 - O Z 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: <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) APPLICANTSTITLE DATE MONTWDAYNEAR <br /> L L1//of E . M `OeAle If 7 - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION III FACILITY# fnCJ900 13 <br /> 9 is 6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> C' 23rd 2-- <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(9-90) FORA-R2 <br />