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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ti Ay�'c6 - -• �o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A ;�� <br /> COMPLETE THIS FORM FOR EACH FACILITYSITE ��"'°""��. <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME _ -.. NAMEOFOPERATOR <br /> Gw � <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> SQ.-, <br /> CITU NAME STATE ZIP OODE SITE PHONE i WITH AREA CODE <br /> BOX s /ur CA 3z] 8- o <br /> TO INDICATE O CORPORATION O immoUM O PARTNERSHIP Q LOCALAGENCY 0 COUNTY-MiENCY <br /> DISTRICTS O STATEAGFKCY FEOERILA(LENCy <br /> TYPE OF BUSINESS Cir, GAS STATION ❑ 2 DISTRIBUTOR O -/ IF INDIAN a OF TANKS AT SITE E.P.A. L D.i(apbW) <br /> Q 3 FARM O A PROCESSOR ❑ a OTHER ATION I <br /> OR TRUST VLANDS O <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 a WITH AREA CODE <br /> l , - X- <br /> NIG7 <br /> HTS: NAME(LAST,F TI PHONE i WITH AREE NIGHTS:NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> H <br /> MAILING OR STREET ADDRESS / ✓ boa binClwm L—J IM MDUAL =1 LOCAL AGENCY =1 STATE-AGENCY <br /> S O CORPORATION =PARTHERSHP O COUNry.AGENCYFEDEML-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> fSGalvn 3 36"3rU <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bbObNi 0INDIVWAL = LOCAL-AGEWY STATE-AGENCY <br /> 0 CORPORATION p PARTNERSHIP Q ODUNTY-AGENCY 0 FEDERA.-AUNCY <br /> CRY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 B questions arise. <br /> TY(TK) HQ F4-[-4] O a y 3 <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: L O II. 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 MONTIWAYNYEAR <br /> LOCAL AGENCY USE ONLY <br /> I—� <br /> COUN Y i JURISDICTION# FACILITYzy] i <br /> L W Go / 9 s <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR-DISTRICT CODE .OPTIONAL <br /> o b I a s bo -3.;) <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) / FIXiam3A412 \ <br />