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�co�• ca <br /> STATE OFCAUFORTSA -.. °+ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� <br /> . 3a. . o <br /> COMPLETE THIS FORM FOR EACH F ILITYISffE <br /> MARK ONLY ❑ I NEW PERMIT O 3 RENEWAL PERMIT EEr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS r NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE LP CODE SITE PHONE 4 WITH AREA CODE <br /> BOX E sc" l�> — CA 953 v - v <br /> TOINgUTE O (]INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY ER156jNTYAGENCY (] STATE AGENCY O FEDEMLAWNCY <br /> DISTRICTS <br /> TYPE OF BUSINESST OAS STATION Q 2 DISTRIBUTOR 5' IRVF INDIAN A OF TANKS AT SITE E.P.A. L D.•(aPknmD <br /> T ON <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonel <br /> DAYS:NAME(LAST,FIRS PHONE t WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE s WITH AREA OOE <br /> a '� r C <br /> NIGHTS: NAME(LAST,FIRST) PHONE i WITH MEA CODE NIGHTS:NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> "'7?Lv+ Gtr 7' If l>G <br /> MAILING ORSTREET ADDRESS ✓ Dw bkdi ED INDNIDUAL =LOCAL AGENCY (]STATE.AGENCY <br /> i /_,V 3 S CORPORATION 0 PARTNERS14P 0 COUNTYAGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE•WITH AREA CODE <br /> S c a..Q oti— e4 YS 3 2 0 <br /> 2�/-8 3P-(nof UU <br /> 111. TANK OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 4 <br /> MAILING OR STREET ADDRESS ✓ bwbYbke4 = INDIVMIAL 0 LOCAL AGENCY O STATE AGENCY <br /> O CORPORATION O PARTNERSHIP p COUNTYAGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODEPHONE✓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 F474 - <br /> � <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.O II. IIL Q <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 MONTHIDAwYEAR <br /> LOCAL AGENCY USE ONLY <br /> CoumN.Y Ir JURISDICTION x FACILITY v <br /> a] � 0 <br /> LOCATION CODE -OPnONAL CENSUS TRACTo -OPTIONAL SUPVISOR•DLRTRN:T CODE -OPTA')AWL <br /> ass-o .2� <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) FORD033AR2 <br />