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� ebaun es <br /> 7F`. STATE OF CALIFORMA <br /> :n4 STATE WATER RESOURCES CONTROL BOARDkv <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A g �e <br /> �,p `, COMPLETE THIS FORM FOR EACH FACILITYISRE <br /> MARK Ot "T',� tNEW Ar^"�in O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SRE <br /> ONE ITEM �'A�iF7 CI(IF,pERM1T F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> EN eF�tM�� <br /> I. FACILITY INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILITYNAME NAME FOPERATOR <br /> L .& <br /> ADDRESS NEA STCROSSST ET PARCEL#IOPrIONAO <br /> 4 c r <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> Wx ^`RPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TO INDICATE �W DISTRICTS <br /> TYPE OF BUSINESS [j?l GAS STATION a 2 DISTRIBUTOR gESERV IDTION IAN #OF TANKS AT SITE I E.P.A. I.D.#(oplimil) <br /> O 3 FARM O 4 PROCESSOR O 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> LLL' 4 r e, Vol, 00 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> r / <br /> V r ✓✓ �� <br /> MAILING STREET ADDRESS bindmc O INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> :9'7' 1 CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL r I rO 0 <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> se aq -a06 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME FOWNER CARE OF ADDRESS INFORMATION <br /> c <br /> MAILING115, <br /> OR STREET ADDRESS '� box b#die 0INDIVNUAL O LOCALAGENCY E71STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY N SZIP CODE PHONE#WITH AREA CODE <br /> TATE <br /> L <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ '4_F4_1- <br /> V. <br /> 4 -V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is ch cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.L-1 II. 111.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLI N SNAME(PRIN EDa SIGNATURE) APPLICANTS TITLE — f DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> / L Z <br /> LOCATION CODE -OPTIONALCENSUS TfiA�T4.Op T/ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Ute/ L/ Z/�O �/1 <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 /> FORMA(9-901) S <br />