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-esoun e <br /> STATE OF CALIFORNIA �. �°+ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "m� y: <br /> TCOMPLETE THIS FORM FOR EACH FACILITYISITE °��,.o�,. <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION V7 PERMANE LO SITE <br /> ONE REM D 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q6 TEMPORARY SITE CLOSURE c� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> OcmarA GA1Ll Rc r( <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAu <br /> N. <br /> CITY NAME - STATE ZIP CODE SITE PHONEi WITH AREA CODE <br /> L rNoIPN CA <br /> TO INDICATE O CORPORATION D INDIVIDUAL O PARTNERSMP LOCAL-AGENCY O COUNTY-AGENCY O STATE AGENCY O FEOERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 3 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. L D.i(apNmiQ <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> IfampeAe- F& _ <br /> MAILING OR STBEETADDRESS box bindia INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> Q, �p D CORPORATION PARTNERSHIP COUNTYAGENCY (]FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> L F NrAPa C4 9S23t <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �+1C as <br /> MAILING OR STREET ADDRESS bwbhKANNI 0 INDIVIDUAL O LOCAL AGENCY M STATE AGENCY <br /> I�CORPORATION D PARTNERSHIP D COUNTYAGENCY 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 F4]4 - Q 2- 2 2 6 <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.O II.vIII.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) APPLICANTSTITLE DATE MONTWDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION M FACILITY a <br /> © 9*44C SO <br /> LOCATION CODE -OPTIONAL CENSUS TRACT S -OPTIONAL 9UPVISOfl-DISTRICT CODE -OPTIONAL <br /> 23. 2-49-- Z 51T z 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 /> FORM3AA2 <br /> FORMA(9-9G) <br />