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_ "esoua ea <br /> • STATE OF CALIFORNIA • ^� �?, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °"��•°""1" <br /> MARK ONLY 0 r NEW PERMIT I] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION IV7 PERMANENTLY CLOSED SITE <br /> 7 <br /> ONE ITEM 0 2 INTERIM PERMIT ---14 AMENDED PERMIT O S TEMPORARY SITE CLOSURE 531 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R ACILI NAME Vv^(/l /�� � / NAMEOFOPERATOR <br /> AO ESS 5 &2 NE ST CRO STREET PMCELN(OPTIONAL)NA(OPTIONAL). <br /> CITYNA E STATE ZIP CO � SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY O STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ( GAS STATION 0 2 DISTRIBUTOR D R SERVATION A OF TANK$AT SITE E.P.A. I.D.#/aplknal/ <br /> O 3 FARM 4 PROCESSOR O 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 AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 /> MAILING OR STREET ADDRESS ✓ lw blydcata O INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP O COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CI7Y NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baa bindia O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> I�CORPORATION Q PARTNERSHIP Q COuNrYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME S7ATE 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 F4-T-41-� <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,O II.❑ 111.❑ <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY 111```���Y,,Y„��) _ <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION COpE,-OPTIONAL CENSUS TRACT# -OeT/ONAL SUPVISOR DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UN SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9-90) FOR(XWA-R2 <br />