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STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD ctb <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EAC FACILITYISRE <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ < AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8i ADDRESS-(MUST BE COMPLETED) V <br /> DBA OR fACILITYNAME ^ NAMEOFOPERATOR <br /> J <br /> COYNESS NEAREST CROSS STREET PARCELa(OPIIONAL) <br /> CITY NAM D� STATE CODE <br /> SITE PHONE a WITH AREA CODE <br /> CA to✓ Box <br /> —ti <br /> TO INDICATE EpleRPORATKIN O INDIVIDUAL I=PARTNERSHIP LOCAL-AGENCY .AGENCY <br /> O STATE-AGENCY ED FEDER/LAGENCV <br /> DISTRICTS <br /> TYPE OF BUSINESS d GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(optimal) <br /> ❑ 3 FARM ❑ 0 PROCESSOR RESERVATION <br /> ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME - CARE ADOREINFORMATION <br /> ffLoSf- <br /> MAILING ORSTIR EETADDRE$S ✓ hoa bintlkau L-JINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> S 13 Iva .�c� p16,1 <br /> O CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDEMLAGENCY <br /> CITU E STp,TE^ 21P PHO NE a WITHAREACODE <br /> 'Z 1� 9 7 7_ l C7 �} <br /> R•ty: <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) iltr ShCn R 13 9 r _�; L I <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Lan Itindkau = INDIVIDUAL ED Look AGENCY Q STATE-AGENCY <br /> __ O CORPORATION O PARTNERSHIP Il coUNTYAGENCY II FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO [4F4] <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: 1.❑ II. 116 <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) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY lz*lw° <br /> COUNTY# JURISDICTION If FACILITY U <br /> S9 <br /> LOCATION CODE -OP770ML CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9-90) FOR0033A-R2 <br />