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STATE OF CAUPORNIA <br /> STATE WATER RESOURCES CONTROL BOARD cot'o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR <br /> EACH FACIUTYSITE <br /> MART(ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 7 7V�4 CHANGE OF INFORMATION ❑ 7 PERM CLpgED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT S'❑-J S TEMPORARY SITE CLOSURE <br /> S <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAMEOFOPERATUR <br /> Cl. S7 <br /> ADDRESS u u - /,� <br /> -7) NEAREST CROSS STREET PARCELA(OPIONAU <br /> _ <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE i WITH AREA CODE <br /> CA 9s r�� 2�5-yYa- zy <br /> TO INDICATE O CORPORATION INDIVIDUAL ] PARTNERSHIP p LOCAL-AGENcr <br /> DISTRICTSp CWNTYwaExcY p STATE-AGENCY p FEOEML-AGENCv <br /> TYPE OF BUSINESS ❑ t GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN i aF TANKS AT SRE E.P.A. 1.D.i(Awi w) <br /> ❑ 3 FARM d PROCESSOR OTHER aORTRUSTVATION <br /> LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS:NAME(LAST.FIRST) PHONE•WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓hm bxgleW p INDIVIDUAL I] LOCAL AGENCY p STATE-AGENCY <br /> 1 p CORPORATION p PARTNERSHIP p COUNrrAGENCY p FEDERALAGENCY <br /> CITY NAME 1 L(C S/�TAT,^E, ZIP cCODE PHONE i WITH CO <br /> AREA DE <br /> S �{7i..� l.� (S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ but Witab p INDIVIDUAL p LOCAL,AGENCY p STATE-AGENCY <br /> p CORPORATION p PARTNERSNP p COUNTI,IGENCY p FEDERAL,IGENCv <br /> CITY NAME STATE I ZIP COOS I 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-F4-] a 3 1 d (O <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.�/II.❑ IN. <br /> ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTVN JURISDICTIONS FACILITY CAq L-7R-n ((o <br /> U <br /> LOCATION CODE -OPTKNiiL CENSUSTFWTi -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THISIS A CHANGE OF7rrEMATION ONLY. <br /> FORM A(940) <br /> w <br /> T <br />