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• ovn es <br /> STATE OF CALIFORNIA • ^P °�, <br /> STATE WATER RESOURCES CONTROL BOARD a` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> °��IIOINI <br /> COMPLETE THIS FORM FOR EACH FACILITYBITE <br /> MARK ONLY F-] I NEW PERMIT O 3 RENEWAL PERMIT [_] 6 CHANGE OF INFORMATION 1�z 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT E::] 6 TEMPORARY SITE CLOSURE -.r^ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ALL -5-rAncE 49 /NC-. Pia GOt}l¢ <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 6011 E sT2EET <br /> CITY t ^D/AME STATE ZIPQODE SITE PHONE#WITH AREA CODE <br /> 369-3s�� <br /> ✓ Box <br /> TOINDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> r DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.#(golional) <br /> RESERVATION <br /> O 3 FARM ] 4 PROCESSOR O 5 OTHER OR TRUST LANDS -2- <br /> EMERGENCY <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAIS: NAM LAST,FIRS �n PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> C,21414 P K. 76 — 36-F/ w 1-19AQA1 s',0 �5f5-S�Ssr <br /> NIGHTS: NAME T,FIRST) <br /> fp9ONE#WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE#WITH AREA CODE <br /> id 77 -23�`O ouiE r1� �/N sv 8�6-0933 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A-u- siivC <br /> MAILING OR STREET ADDRESSr �jEGr ✓ box b Indlow = INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 6411 E / C SrYc.. � COflPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCY <br /> CIT;NAME / STATE ZIP CODE HONE#WITH AREA CODE <br /> L 952`/O 2d9 36 3S�h <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> sT r c <br /> MAILING OR STREET ADDRESS ✓ box b NMbau 0INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> 60// E PINE 57_R2Q:77_ CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIT Lo pl STATE� ZIP6-CODE7- <br /> PHONE#WITH AREA CODE <br /> IV.. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-T-41-� <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. II. III.❑ <br /> THIS FORM HAS BEEN COMPL ED UNDER PE ALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED851GNATU ) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> p5M �/L2�i p�uDucTtO.L✓ M�,4� /;? -92 <br /> LOCAL AGENCY USE ONLY <br /> COUN-.Y# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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) FOR0037A-R2 <br />