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p�sooe es <br /> • STATE OF CALIFORNIA P `'w <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A n� �e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �'bsp""�x <br /> MARK ONLYNEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SIDE <br /> l <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) iJ <br /> OBAO ACILITYNAME NAME OFO TOR <br /> ADDRESS NEARES OSS ST EET AR LA PrgNAU <br /> # <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE O CORPORATIONINDIVIDUAL 0 PARTNERSHIP D UXCAL-AGENCYD COUNTY-AGENCY DSTATE-AGENCY 0 FEDERAL-AGENCYDIST <br /> DlsrRlCTScrs <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.R A. I.D.#(optimal) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ao - <br /> NIGH TS: N E(LAST,F S HONE*'WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITHAREACODE <br /> t <br /> II. PROPERTY OWNER INFO ATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box lo Indicate O INDIVIDUAL 0 LOCALAGENCY O STATE AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPILE ED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET—ADDRESS ✓ box 0Indicate 0 INDIVIDUAL <br /> E] LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NU ER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and bill) 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 AN II-UNG: 1.1:1 IT. 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 MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY �Gb <br /> C�OUNTYa.�I�# JURISDICTION# FACIL YIt <br /> �.GLL-.I EI]7I /� <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT# -OPSUPVISOR-DISTRICT CODE -OPTIONAL <br /> T( AL <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) /'L (�.—x� FOR003 {i2 <br />