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OJa p <br /> STATE OF CALIFORNIA r/ <br /> :° c�'; <br /> STATE WATER RESOURCES CONTROL BOARD s '<g ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�`� vs <br /> COMPLETE THIS FORM FOR EACH FACILIT <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY y <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT [L] 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DGA OSp�A I'LI]�N�;;E �� �� NAME OF OP TOR �l <br /> IcU Viyq N J)l c 00 J//�1C`� 7ruoc c.�12A /, Irl Ton <br /> cq n <br /> ADDRESS NEAREST CROSS STREET PARCEL I(OPTIONAL) <br /> lb;aQ 7%c_ -V QoR P <br /> CITY NAMSTATE ZIP C DE SITE PHONE a WITH AREA CODE <br /> an S36 ( CA �iJ rv� 09-5991/, <br /> TO INDICATE O CORPORATION D INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS T OAS STATION 0 2 DISTRIBUTOR / IF INDIAN N OF TANKS AT SITE E.P.A. I.D.a(Wp ) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS (/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS' ME(LAST.FIRST) PHONE#WITH AREA E DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NNCRN H IR Run o°/-5?C( <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 7W P, �RNYY\ D� `��9-7313 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> t&Pign <br /> MAILING66 <br /> REETADDDRESS INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> MlGhe ,e <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> Y NAME STATE ZIP C E PHONE# ITH A EA CODE <br /> qu+N�4n �i1ws o <br /> cf c{Cd l 6/- �f <br /> CIT <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Xm0mXa% OINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTYAGENCY 0 FEDEMLAGENCY <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 F474 - <br /> g <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 II. 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# O y JtmCO zZ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> oS -a 315 e3 2,61 -Z9 rZ <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 /> // FORWStAfi2 <br /> FORMA(9-90) <br />