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-,60UR C9 <br /> STATE OF CAUFORMA is `Os, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH F BRE <br /> MARK ONLY r__j t NEW PERMIT O S RENEWAL PERMIT EgS CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE a <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OGA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CAI/ BOX <br /> TOINDIC TE 0 CORPORATION D INDIVIDUAL PARTNERSHIP D LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> 77' <br /> VPE OF BUSINESS 0 GAS STATION 0 2 DISTRIBUTOR IF✓ IF INDIAN #OF TANKS AT SITE E.P.A. L 0.#(cp#ma# <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) �HrE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> -5 wY ei Lu ri 77 .- 9`?- 213, 5' - ' <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> k .we R c I <br /> MAILING OR STREET ADDRESS ✓ boa binEiala D INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D 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 /> S G '—Ue 4 S z <br /> MAILING OR STREET ADDRESS boa b Intlb## D INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION D PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#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-J-41-I <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo r schecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L D-E::] III.ED <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 /> COUN MY# JURISDICTION# FACILITY# <br /> o a v o / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2323 3db <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) 1 A\ <br /> FORM3A-R2 <br /> 1 G (\/ � /� 0 0 �a 1 <br />