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sao- e <br /> STATE OF CALIFORNIA -� '"" `', <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C"--UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� v; <br /> COMPLETE THIS FORM FOR EACH FA Y/SrTE Vpe M�� <br /> MARK ONLY 0 T NEW PERMIT O 3 RENEWAL PERMIT EL,4CHANGE OF INFORMATION O 7 PERMANENTLLOSE <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> r— D {ZtCL <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1'6,-/'f tY1Gp <br /> CITY NAME STATE ZIP CODE SITE PHONE t WITH AREA CODE <br /> I/ BOX S CA 95 Zv _y / <br /> T NDICATE O CORPORATION NOIVDUAL I=PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY I1 FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 T GAS STATION O 2 DISTRIBUTORO ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.O.N(UPAIWO <br /> RESERVATION <br /> O 3 FARM O 6 PROCESSOR 5 OTHER ORTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> F <br /> S: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRSn PHONE N WITH AREA CODE <br /> TS: NAME <br /> (LAST, ST) PHONE$WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> li <br /> MAILING OR STREET ADDRESS `7 buX loktlicab INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY <br /> R7 13e ,r.M(H A/v 1A =CORPORATION = PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE$WITH AREA CODE <br /> � r 9sw� 2a9 - sem- Yu/ <br /> ill. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 3C4rv%.P, a5 -X= <br /> MAILING OR STREET ADDRESS boxblMkW 0 INDIVIDUAL O LOCAL AGENCY Q STATE-AGENCY <br /> S-r-E$Dtie R O CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEOERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-T4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O H- 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY �e <br /> COUh^Y tl JURISDICTION N FACILITY III, <br /> 1 10 10 1Z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o/ 138 1 <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) FOROW9AJR2 <br />