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STATE OF CALIFORNIA ecoors es <br /> STATE WATER RESOURCES CONTROL BOARD• =� c e; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A v <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 3 NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITEO 2 INTERIM PERMIT � 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA CR FACILITY NAM <br /> NAMEOFOPERATOR <br /> ADD ESS /\ ! <br /> D 1, NEAREST CROSS STREET PARCEL i(OPTUNAL) <br /> C NAME <br /> STATE ZIP CODE /' SITE PHONEi WITH.,ARE CODE <br /> I/ Box CA 9 �G°G1 �GtS 7 <br /> TO INDICATE O CORPORATION IVIDUAL I= PARTNERSHIP O LOCAL.AGENCY <br /> DSTNCTS 0 COUNTY-AGENCY 5TATE AGENCY FEDERALAGENCV <br /> TYPE OF BUSINESS O 1 GAS STATIflO p DISTRIBUTOR O ✓ IF INDIAN i OF T�S AT SITE E.P.A. I.D.i(op//map <br /> Q 3 FARM O 4 PROCESSOR THEIR RESERVATION <br /> OR TRUST LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonel <br /> DAYS: E(LAST,FIRST) D� HON i W TH ARE^CApE� <br /> GAO/ DAYS: NAME(LAST,FIRST) PHONE i WITH AREAE <br /> NIGHTS; NAME( ,FIRST) PHONE#WITH AREA COD <br /> NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED <br /> D CAREO[NAME <br /> AILING GR STREET ADDRESS <br /> ✓ DoxbbEicaleof <br /> NAa L7 COF ORATION PARTNERSHIP LOCAL-AGENCY (]STATE-AGENCY <br /> COUNTY-AGENCY Q FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> I OWNER <br /> �i v. ^ CARE OF ADDRESS INFORMATION <br /> T <br /> MAILING OR STREET ADDRESS <br /> 2�ry /_.-v�� hox blMkaze DIVIDUAL <br /> CITY NAME Com!/ O CORPORATION PARTNERSHIP SAL-AGENCY 1=1STATE-AGEHCY <br /> Q CAUMy'AGENCY ED FEDEIUL-AGENCY <br /> G STAZIP CODE HONE WITH6REACODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 4 q _ •Call(91�7� gp if questions arise. Zd <br /> �-�-�-n <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: <br /> I.� IL IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANDCORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) <br /> APPLICANTS TIRE DATE <br /> MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN;Y# JURISDICTION# <br /> FACILITYA <br /> LOCATION CODE -OPTIONALCENSUAL <br /> O 3 QCC.•�l SUPVISOR-DISTRICT CCODE -OPTIONAL � (/ /r �9 <br /> 3Z � <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) <br /> 5 IL LA T/ 3� FOR3033A R2 <br />