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ftyOVP f8 C4 <br /> STATE OF CALIFORNIA ✓ ,� ''� <br /> STATE WATER RESOURCES CONTROL BOARD AY r.� a <br /> �DERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � oe <br /> COMPLETE THIS FORM FOR EACH FA /SITE <br /> MARK ONLY O t NEW PERMIT ED 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SIE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE !�`3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> TCPOI �rn�I <br /> ADDRESS ( /^ NEAREST CROSS STREET PARCEL$(OPrIDNAL) <br /> Z <br /> . / / �.-on <br /> CITY NAME STATE TP CODE SITE PHONE a WITH AREA CODE <br /> cfvh CA <br /> ✓ <br /> BOX <br /> TOINDICATE ONPCOMTION O INDIVIDUAL O PARTNERSHIP AL-AGENCY O COUNTY-AGENCY 0 STATE-AGENCY [=IFEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F7 t GAS STATION Q 2 DISTRIBUTOR 0 p SEIF 1 <br /> RVADTION NOF TANKS AT SITE E.P.A. I.D.a(cplbwlJ <br /> Q 3 FARM 0 4 PROCESSOR 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 N WITH AREA CODE <br /> 1Yr -'IS`c1D <br /> NIGHTS: N ET,FIRST)1 PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa ,->. <br /> MAILING OR STREET ADDRESS ✓ 6oxblrMkaN INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> I�CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Wx b Mute INDIVIDUAL ED LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP D COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME $TATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boxLPF G ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L 11.0 III.I= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR WTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YW <br /> LOCAL AGENCY USE ONLY <br /> CCOOU�NTTY�# JURISDICTION# FACILITY# �}gTQO a� <br /> LOCATION CODE -OPTIONAL GEN SU$TRACT0 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ® / 3n s a <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) <br /> FORMA R2 <br /> Al y' 2 <br /> \rte <br />