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*tyal`,•8 C� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH F Y1SRE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE aq ) <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> V C' <br /> ADDRESS NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> 72-7 6 <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> 12 i2 a A �� 79--51/ <br /> BoX f To INDICATE oRPORATION Q INDIVIDUAL Q PARTNERSHIP AL•AGENCY [] CouNTY-AGENCY 72 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR © J IF INDIAN s OF TANKS AT SITE E.P.A. I.D.+(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> J ' V '-r &E' C., C( c & `I 5I(--.G6�- <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S 4 -gyp cx S <br /> '7- <br /> MAILING <br /> MAILING OR STREET ADDRESS ✓ box lo indicate Q INDIVIDUAL Q LOCAL-AGENCY [j STATE•AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Ste . s <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL <br /> [] LOCAL-AGENCY QSTATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEs WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cail(9 16)739-2582 if questions arise. <br /> TY(TK) H4 4 4 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless boxj or II is checked, <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS T,ITLE DATE MONTFUDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN'.Y# JURISDICTION# FACILITY# <br /> 119 1 (: D I / � 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT M -OPTIONAL SIIPVISOR-OISTR ICT CODE -OPTIONAL <br /> �) 3 J�v 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 /> FO <br /> R0033A�R2 <br /> FORMA(9-40) r� <br />