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C5oL1RC�S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Y o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a <br /> • ��1 i-pP ti's <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:D 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAD FA LIN NAME 000 o NA�OF O <br /> PERATOR <br /> eA <br /> ADQR (y�*� NEAREST CROSS STREET PARC N(OPTIONAL) <br /> I IV�z &e� <br /> CITY N STATE ZIP CODE ,$JTE PHONE#WITH AREA CODE <br /> CA '/fi/0 452 _ <br /> TOINDIICCATE I�CORPORATION = INDIVIDUAL 0 PARTNERSHIP [_1 LOCAL-AGENCY Q COUNTY-AGENCY QSTATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTORI� ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optionaf) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY © FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> A OF OWNS /'�+I1rI JF�� /rG�/4XrC I C RE OF ADDRESSINFORMATIO I '�� <br /> dL V 1 , cYyl //d,�eL ��� <br /> 711G,OR STj((ff����VT DRESS ✓ box 0indicatee [� INDIVIDUAL I� LOCAL-AGENCY ATE-AGENCY <br /> VV//� re- J�� Sj/�ji V []CORPORATION I� PARTNERSHIP COUNTY-AGENCY © FEDERAL-AGENCY <br /> CI NAME STAT, ZIP C E II PHONESWITH REACO 3 <br /> - r I�l�r o '�J <br /> IV. BOARD OF E UALIXATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)739-2582 if questions arise. <br /> TY(TK) HO 4 4 - <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.D II.D III.IV <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHMAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> r �7 <br /> LOCATION CODE -OPTI_VyA{ CENSUS TRACT#_ ONION SUPVISOR-DI TRICT CODE -OPTIONAL <br /> (p{JJ') fJ -Z JJ(� , I <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 /> FOROOMA-R2 <br /> FORM A(9-90) //ft/ <br />