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\ STATEOFCAUFORMA <br /> k STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC FACILRYISRE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT E95 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O q AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFACILITY N DIME _ �O NAME OF OPERATOR <br /> ADDRESS iNEARESTCROSSST EET PARCEL0(OPTDNAL)•�{ti fl�l ze/� a / C oyo -613-Z <br /> CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> 5-lLoer�(cdaa CA 67 Oto Vam) Ltzg>-vW09 <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY ED FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ( GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN R OF TANKS AT SITE E.P.A. I.D.•(oplAriell <br /> 3 FARM 6 PROCESSOR 5 OTHER RESERVATION O <br /> 0 O I� OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE �op{�p,YyI/: NAME MST,FIRST) PHONE A WITH AREA CODE <br /> a4 OL or z^) 76 -3146 Zia. �) 6fr,3/06 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> la's as ki-t, (Zog ) 468' -31616 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET MDRESSV box b NMlcW = INDIVIDUAL -AGENCY O STATE AGENCY <br /> � <br /> ZtZ B• wPe$E,e c-0O 1 r /-FOL ISE Q CORPORATION = PARTNERSHIP In COUNTY-AGENCY FEDERALAGENCY <br /> CITY,g�� ST ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNERW.?— <br /> CARE OF ADDRESS INFORMATION <br /> Son v/h C• - � . /llor� <br /> MAILINGORSTRE ADDRESS b°abindPab = INDIVIDUAL O Y 0 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP CWNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE 7 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) HQ 44 -� <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.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 a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN 1Y N JURISDICTION a FACILITY p <br /> 3 F5Y�-?' oo ! 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O y3 -8D �iZ E—r3(?-'iia <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITEINFORMATION ONLY. \ <br /> FORMA(9-90) <br /> FORMA-R2 <br />