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^tinny C <br /> 14.0p,14.0p, STATEOFCAUFORMA '• t <br /> STATE WATER RESOURCES CONTROL BOARD ;` ��^ 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�� n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O i NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 141eftveC ✓'�1ft4'Tloa <br /> ADDRESS NEAREST CROSS <br /> �STREET <br /> / PARCEL#(OPTIONAL) <br /> ggzb WAS ts,J*=t4u4."tt-1 c=Rt -\ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> •I INDICATE BOX <br /> TOINLtllj• CORPORATION E:j INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 3 GAS STATION 2 DISTRIBUTOR Q RESERVATION <br /> #OF TANKS AT SITE E.P.A. I.D.#(waplOmU) <br /> Q 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS �iJ 9B-I-TT-12Z� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CGDE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Wpt lC� WIL,-L-I 41S-lzko-b-7 � md'-f%=14 cowme <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> M MAdI t(GJPAJC� CeAllan ew-99t-•31047 =ot-A C;I hICA CE--t-nCr-- 8a�-4 k?r57 <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CvtI LI-Z•P.- .�n>✓ <br /> MAILING OR STREET ADDRESS V bon bindbW INDIVIDUAL OLOCALAOENCY =STATE-AGENCY <br /> C7ta(-(�.�A 1<0 aj<-o rt.6Z2t< [O'CORPORATON Q PARTNERSHIP =COUMYAGENCY = FEDERAL-AGENCY <br /> CI� STATE ZIP COOS PHONE#WITH AREA CODE <br /> � 7-7092 '992--2� <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS b kW INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> 7� CLQ &ptLj �(�, GjA�t-[� Izo:ty CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN NAME BTATE ZIP CODE PHONE#WITH AREA CODE <br /> C'e'- C> 1 -4ts 2A"-S-7ez <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HQ F474 - 01a 147 B 5 <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.Q II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICA TS pMEI P, I R ED&EIIGNA�AT APPLICANTS TITLEDATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY A' <br /> COUNTY* dory ft JURISDICTION FACILITY# <br /> LOCATION COQ -OPTIONAL CENSUS TRACT#:OPT1OAAL SUPVISOR-DISTRICT CHIDE -OPTIONAL jvj <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 /> FOR0033A R2 <br /> FORM A(9.90) <br /> —J <br /> s <br />