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P�SOVgCCS cG <br /> ti ;9 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD g <br /> UNDERGROUND STORAGE TANK PERMIT APPtiCAfiION FORMA <br /> 4LIF R N1f <br /> COMPLETE THIS FORM FOR EACH FACILITYJSITE <br /> MARK ONLY fl NEw PERMIT <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C <br /> ONE ITEM � 2 INTERIM PERMIT <br /> O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> AME OF OPERATOR <br /> DBA OR'FACILITY NAME -r= <br /> NEAREST CROSS STREET <br /> PARCEL#(OPTIONAL) <br /> ADDRESS <br /> + STATE ZIP CODSITE PHON WITH AREA CCDE <br /> CITY NAME CA '5 — <br /> CORPORATION INDIVIDUAL l� PARTNERSHIP L LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY � FFDERAL-AGENCY <br /> "/ BOx DISTRICTS <br /> TO INDICATE <br /> hF INDIAN #DF TAN9tS AT SITE <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR 5 OTHER �DRR SERVRUST ATION <br /> 3 FARM 4 PROCESSOR 0 <br /> EMERGENCY C7�ZTRSON PRIMARY} ANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY) optional <br /> DAYS: NAME(LAST,FIRST) #WIT AREA CO EDAYS: NAMEST FIRST PHONE x WITH AREA CODEPHONE#WITH AREA CODENIGHTS: NA A T•F1 ST} #WITH AREA E NIGHTS: NAME(LAST,FIRST) <br /> 11, PROPERTY OWNER INFORMATION• M ST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> box to indicate i] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS iD CORPORATION I� PARTNERSHIP COUNTY-AGENCY OFEDERAL-AGENCY <br /> STATE ZVP CDDE PHONE#WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLET ) cnRE DF ADDREss INFORMAnoN <br /> NAME OF OWNER <br /> box So Indicate tiNDIVIDUALf[--1 <br /> ENCY [� STATE-AGENCY <br /> MAILING OR STREET ADDRESS (�CORPORATION [] PARTNERSAGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE #WITH AREA CODE <br /> CITY NAME <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-25B2 if questions arise. <br /> TY(TK) HQ 4 4 <br /> 1LLINAAD RESS Legal notification and billing will be sent to the tank owner unless box II oris checked. <br /> V. LEGAL NOT]F1CATlOtJ AND <br /> SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS TITLE DATE MONTHIOAYNEAR <br /> APPLICANTS NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COLI JURISDICTION# FACILITY# <br /> + SUPVISOR•DISTRICT COQE OPTIONAL <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* PTIONAL <br /> NIED BY AT LEAST(1)OR MORE PERMIT APPLICATION FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ORLOQY93A-R2 <br /> THIS FORM MUST BE ACCOMPANIED �� <br /> FORM A(9.90) �4 �_J l4 <br /> t-17 <br /> A 4o r m -�- �� �� �li'(,71AF✓'� <br /> ---�K aiiq <br />