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FR R fn i N K <br /> ` 46 <br /> VR <br /> `� ST TE FCAUPORNIA a °`���,•• c <br /> STATE WATER RESOURCES CONTROL BOARD i � ° <br /> �� l( <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� vs <br /> ��x,fOPM�f <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION EMF7 PERMANENTLY CLOSED SR <br /> ONE ITEM 2 INTERIM PERMIT Q4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> :1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS- M ETED) <br /> AOR FACILITY NAME AME OF OPERATOR <br /> her <br /> NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> JV <br /> G STATEZIP CODE SITE PHONE AREA CODE <br /> CA <br /> T NDIICATE O CORPORATION INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS �I I GAS STATION Q 2 DISTRIBUTOR 0 RESEIF INDIAN RVATION 0 OF TANKS AT SITE E.P.A. I.D.N(optimal) <br /> ARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS ' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> MAONIG bpSTREET ADDRESS re box 0Indkale C=j INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> Iqlq0 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYAM STATE ZIP CODE PHONE;I WITHAREACODE <br /> C 0 ao o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindkau O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION D PARTNERSHIP COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME 4TATE ZIP CODE PHONE N 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-F4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank 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. III.0 <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 MONTH/DAY/NEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYN JURISDICTION M <br /> Ln I I 1,a151317 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR•DISTRICT CODE -OPTIONAL <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) �FOR9999MR2 <br /> Ab c Aa✓4-P_ Ab <br /> ��2agc Lrk <br /> 4Aa4t �( <br />