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• °"�.n„' <br /> STATE OF CALIFORNIA �P c <br /> STATE WATER RESOURCES CONTROL BOARD ;` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ami <br /> Z% COMPLETE THIS FORM FOR EACH FACILNYISITE <br /> MARK ONLY 0 t NEW PERMIT 0 3 RENEWAL PERMIT lers CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT [:_] 6 TEMPORARY SITE CLOSURE Y� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> r Ew E v,E / <br /> ADDRESS NEAREST CROSS STREET PARCEL N IOPTIONAO <br /> CITY NAME STATE ZIPCODE SITE PHONE#WITH AREA CODE <br /> Gvv CABOX <br /> q Z D 'WITH <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY E:1 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR D q SERVADTION #OF TANK T SITE E.P.A. L D.#(ap#ona# <br /> 3 FARM 4 PROCESSOR Q�5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N (LAST.FIRST) PHONE#WITH AREA CODS DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME ILAST,FIRST) PHONE# ITHA PACODEf NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 67�t <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Y' <br /> MAILING OR STREET ADDRESS ✓ box bintlbale INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> U w� O CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODEHONE#WITH AREA CODE <br /> Gv Z v X177-6z9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS'/ box bWkaW DIVIDUAL E7:1LOCAL-AGENCYOSTATE-AGENCY <br /> CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE & PHONE WITH EACODE <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 ch ked. <br /> CHECKONEBOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.E:] II. 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 a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> 15 <br /> LOCATION CODE -apTtoNAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ' <br /> 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 /> FOR0033A-R2 <br /> FORM A(9-90) <br />