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STATE OFCAUFOgNIA <br /> 0 ourz e <br /> STATE WATER RESOURCES CONTROL BOARD ?` • 'o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :_�� y; <br /> Cx P � • O <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE ��lnon B��. <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT a a TEMPORARY SITE CLOSURE a <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELp(OPFKINAq <br /> CITY NAME STATE ZIP CODE SI E#WITH AREA CODE <br /> S CA r -civ -Y73 <br /> I/ sox <br /> TO INDICATE ]CORPORATION (] INDIVIDUAL ] PARTNERSHIP (]LOCAL-AGENCY coUNrVAGENCY ] STATE-AGENCY E <br /> TS FEDERAL-AGENCY <br /> flIC <br /> TYPE OF BUSINESS O ) GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E. <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR <br /> 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 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /� /1 CARE OF ADDRESS INFORMATION <br /> /l U 4u.0 r <br /> MAILING OR STREET ADDRESS <br /> O /d57 '- ✓ CboOxgbPOinRdkATalIOe N ]] PINADRITVNIDEURASLHIPOLOCAL-AGENCY ]STATE-AGENCYf <br /> = COUNTY-AGENCY ] FEDERALAGENCY <br /> CITY NAME rl "'o STATE ZIP CODE <br /> DE 4J PHONE WITH AREA CODE <br /> /V�/ ' o !6 - yz-Y73 <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b"I I] INDIVIDUAL O LOCAL-AGENCY ]STATE-AGENCY <br /> ]CORPORATION ] PARTNERSHIP I] COUNTYAGENCY ] FEDERAL-AGENCYCITY NAME STATE ZIP CODE 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 4 4 _ a <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. I. 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&SIGNATURE) APPLICANTSTITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COCOUNTYI# JURISDICTION# ��� FACILITY III <br /> 14L_-1 IJ � Irr <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 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 /> FORM A(9 90) FOR0W3A-R2 <br /> 0 NO IW ID S <br />