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• • aun e <br /> STATE OFCALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD A' ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY1SITE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBBAA�ORFFACILITY NAME ��j•.//+� ` NAMEOFOPERATOR <br /> ��yr fi F� f J.f•�/� /'5. <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> /// S- J`-7a �/ s^i Oo <br /> CITY NAME STATE ZIP COD ITE PHONE*W ITH AREA CODE <br /> 11010.7— CA <br /> ✓ BOX <br /> TOINDICATE D CORPORATION (] INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR I= RESERVAIF NDIIAN ON #OF TANKS AT SITE E.P.A. I.D.*Wbonal) <br /> Q 3 FARM O 4 PROCESSOR5 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 /> IL PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> L'D6rS/diOGG / ad .�.< <br /> MAILING/OR STREET ADDRESS ,/ �•..� ✓ bu In Miab [D INDIVIDUAL 0 LOCAL-AGENCY O STATEAGENCY <br /> CORPORATION D PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE1,RHONE#WITH AREA CO/IE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> AILING OR STREET ADDRESS ✓Cox bl INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 5 lJ`�/�G +Td/`! ] / - RPORATION ] PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WIbTH AREA CODE <br /> d U � - <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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANDP6RRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION# FACILITY# <br /> 1317 ;A�'l // R/i/ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL <br /> o a Zv <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 /> FOR0033AR2 <br /> FORM A(9.90) <br />