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a <br />STATE OF CALIFORNIA • <br />STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYBfTE <br />MARK ONLY <br />® 3 NEW PERMIT <br />O 3 RENEWAL PERMIT <br />❑ <br />5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br />ONE ITEM <br />2 INTERIM PERMIT <br />4 AMENDED PERMIT <br />❑ <br />6 TEMPORARY SITE CLOSURE d <br />CITYNAME <br />I. FACILITYISITE INFORMATION & ADDRESS • (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />V <br />t v M <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL (OPTIONAL) <br />S W. COp-AjGk o F 4A ti to 4- Irrl <br />Caft1rtiJSE <br />Q p -r <br />CITYNAME <br />STATE <br />ZIP CODE <br />SITE PHONE %WITH AREA CODE <br />Meg <br />CAI <br />PHONE%WITH AREA CODE <br />Ll#kyoam <br />TO INDICATE 0 CORPORATION Q INDIVIDUAL 0 PARTNERSHIP O LOCAL -AGENCY COUNTY -AGENCY O STATE -AGENCY O FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORO <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. % (CPNonal) <br />Q 3 FARM A PROCESSOR O 5 OTHER <br />RESERVATION <br />OR TRUST CMOS <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON ISECONOARYi. notional <br />DANAME (LAST, FIRST) r PHONE # WITH AREA CODE <br />VJ0/, <br />DAYS: NAME (LAST, FIRST) PHONE % WITH AREA CODE <br />soN Al 7C)7_S - 6q I <br />t v M <br />NIGHTS: NAME (LAST. FIRST) PHONE %WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE %WITH AREA CODE <br />/ L /�%6N7 to /N 7' $ ' 969/ <br />✓ wxbtrdbat% 0 INDIVIDUAL <br />II. PROPERTY OWNER INFORMATION - (MUST RE COMPLETED( <br />NAME <br />Ce <br />CARE OF ADDRESS INFORMATION <br />DATE MONTH/DAYNEAR <br />t v M <br />N <br />o <br />MAILING OR STREET ADDRESS <br />✓ wxbtrdbat% 0 INDIVIDUAL <br />0 LOCAL AGENCY 0 STATE -AGENCY <br />Q p -r <br />CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY O FEDERAL -AGENCY <br />CITVN E <br />SF <br />ZIPCODE <br />PHONE%WITH AREA CODE <br />E <br />(cL <br />9�5/b <br />b7-7,VS-66 <br />III. TANK OWNER INFORMATION - (Mt1ST RE COMPI mm <br />NAnWNERCARE <br />Co <br />OF ADDRESS INFORMATI ON <br />DATE MONTH/DAYNEAR <br />uS O F <br />t <br />"N <br />MAILING OR STREETADDRESS (yQ <br />OoxbinObat% 0 INDIVIDUAL <br />O LOCAL -AGENCY Q STATE -AGENCY <br />'p D �( <br />CORPORAIION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERALAGENCY <br />CITY;E <br />TATE <br />Sr9 <br />ZIP CODE <br />PHONE WITH AREA CODE <br />Niru <br />y5/ <br />7o7��'t5-669/ <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (TK) HQ F4-[-4] - D ! $ <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. 1-:1 II.'pmq III. E <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPL ANTS NAME INTED&SIG SIGNATURE) <br />APPLICANTS TITLE <br />DATE MONTH/DAYNEAR <br />��, CY°E & InWvgp <br />� <br />/lfi <br />09-zR-9S <br />LOCXL AGENCY USE ONLY/ U <br />COUNTY # JURISDICTION # FACILITY # <br />m "to 7 <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 />FORMA (9-90) <br />FOROD33A-R2 <br />