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STATE OF CAUFORMA `meq <br /> STATE WATER RESOURCES CONTROL BOARD A'4 m' 'o, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A " ` ys <br /> C <br /> ro . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ��`��°""�� <br /> MARK ONLY Q t NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q A AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAt <br /> 1p 1 GLC 2 <br /> AC ITY NAME NAME OF OPERATOR <br /> ? 'S <br /> ADDRE L4NEAREST CROSS STREET PMCEL r(OPTKNiAy <br /> ass W• N�w <br /> CITY NAME STATE ZIP CODE SITE PHONE s W 17H AREA COOS <br /> �S C� CA <br /> TO INEXCCATE p CORPORATION p INDIVIDUAL p PARTNERSHP p=ALAGENcY p COUNTYAGENCY p STATE-AGENCY <br /> DBTRICTS p FEOERAL,IGENCY <br /> TYPE OF BUSINESS p ) GAS STATION Q 2 DISTRIBUTOR p ✓ IF INDIAN 1#OF TANKS T SITE E.P.A L D.#(apo") <br /> RESERVATION <br /> Q 3 FARM a d PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#NTH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX 10wm p INDIVIDUAL p LOCAL4MCY p STATEAGENCY <br /> p CORPORATION p PARTNERSHP p COUNTY-AGENCY p FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS6.00 .W p INDIVIDUAL p WCA4AGENCY p STATE AGENCY <br /> p CORPORATION p PARTNERSHIP p COUNTY-AGENCY p FEDERAL-AGENCY <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 4 4 -Fj—F-T—T—F <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: 1.0 II.O III. <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# CbYx• JURISDICTION# FACILITY# <br /> aFT Pe E5 R3 2 1 41 <br /> LOCATION COOEJ�qNAL CENSUS TRA T#=OPTIONAL SUPVISOR�1DISTRICT CODE •OPTIONAL <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) FOROMAA2 01� <br />