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�-� ls7 Yl.lYrc) l✓v� GriA24!_E_. F .T S 5 (.tk-.- �' / vu.�� - <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD io <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y; <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT E 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED SI E <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAORFACILI AME NAMEOFOPERATOR <br /> ADDRESS <br /> G <br /> /� L O /- -as y 7 n y ^ NEARESTCROSS TRE$ Er PARCELN(OPrIONALI <br /> CITY NAME LTJ I /a.K/, �+�--> -UJLa/ILY[_!•�^`i <br /> ��_ STATE ZIP CODE SITE PHONE;1 WITH AREA CODE <br /> ✓ BOX '�Uj/LJ ca q a o a 9 `f —8 104 <br /> TO INDICATE CORPORATION INDIVIDUAL (] PARTNERSHIP (] LOCAL-AGENCY <br /> DISTRICTS �UMVAGENCY (] STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN *OF TANKS�SITE <br /> O 3 FARM O 4 PROCESSOR 5 OTHEfl O RESERVATION <br /> OR TRUST LANDS <br /> =INFO <br /> GE CY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> T) PHONE*WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE*WITH AREA CODE <br /> ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NER INFO ATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS - ✓ box blMkau I] INDIVIDUAL <br /> ]CORPORATION LOCAL-AGENCY ]STATE-AGENCY <br /> CITY NAME ] PARTNERSHIP ]COUNTY-AGENCY (]FEDERAL-AGENCY <br /> 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 ✓box b Nbkau <br /> (]INDIVIDUAL ] LOCAL.AGENCY ]STATE- <br /> AGENCY <br /> CITVNAME — — (]CORPORATION ] PARTNERSHIP ] COUNTY-AGENCY (] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FE CCOUNT NUMBER-Call(9%)739-2582 if questions arise. <br /> TY(TK) HQ4 4 - Q 8 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS L gal 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.O II. HL <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 <br /> DATE MONTWDAVNEAR <br /> LOCAL AGENCY USE ONLY r a <br /> CI�OUNTY# JURISDICTION# F�ACCII/LLII�TY�Y##� <br /> LOCATION CODE -OP77ONAL <br /> rp <br /> CENSUSTRACI OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> aY � <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 /> FORM A(9-90) FOR0033A-R2 <br />