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STATE OF CALIFORNIA <br /> • coon e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC <br /> F-FACILfTYISRE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORRFFACILITY <br /> /NAME NAME OF OPERATOR <br /> `- NEAR�CREET PMCELNIOPfpNAL) <br /> CITY NAMES 7 STATE ZIP CODE ITE PH E#WITH AREA CODE <br /> DZ cA 36�t-/oSs <br /> TO INDICATE O CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY <br /> DISTRICTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN S AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREACODE <br /> NIGHTS: NAMEL. T,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 /> �� ��G ,�fcr�io-✓�,Fir <br /> MAILING OR STREET ADDRESS ,./,�'_-/ `� icaU 0 INDIVIDUAL = LOCAL-AGENCY—DSTATE-AGENCY <br /> 1411" S- %/��f—/N1✓ ZI CORPORATION PARTNERSHIP = COUMY.AGENCY = FEDERAL-AGENCY <br /> CITU NAME STATE ZIPCODW HON #WITHAREAOODE <br /> dr1pdQ.Z;' -m <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box Io lydkne INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY <br /> /`// r• �'/x Ton✓ -s% I�CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> Z) 06�-/GAS <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> �5q e <br /> LOCAT NCODE -OPTIONAL CENSUSTRACT 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 srrE INFORMATION ONLY. <br /> FORM A(9-90) FOR0033A R2 <br /> 0 0 4X <br />