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a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACIUTY/SrrE <br /> MARK ONLY Q 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY_CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 d AMENDED PERMIT O S TEMPORARY SITE CLOSURE d � <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY E NAMEOFOP ATOR <br /> P�l�/ ' s �U Cc✓G pr c 1'1141 <br /> ADDRESS ) NEAREST CROSS ST EET PATiCE COPTIONAL) <br /> pp3 <br /> CITY NAME STACEA A 1 ZIP COC TE PHONE L3WITHcRE%CS7` <br /> 1/81 or <br /> TOINDICATE <br /> ✓ Box RPORATION F-7INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY C-1 rOOUNTY-AGENCY STATE-AGENCY 1� FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN AT SITE E.P.A. 1.D.#(optima/) <br /> O 3 FARM Q A PROCESSOR RESERVATION <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM LAST,FIRST) PHON #WITH AREA E DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> . / � z4 z3 - S <br /> NIGHTS: NA ( ,FIRST) PHO #WITHAREACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CO DE <br /> II, PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bIndicate [71 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY 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 /> �— <br /> MAILING ORSTREET ADDRESS ✓ bob Mica Ij INDIVIDUAL 0 LOCAL-AGENCY 7-1 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE 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 [4-147- 2 2 S <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: I. II.O III.O <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/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# - SDE (d <br /> d0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3-/o-9z <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) <br /> FOR0033A R2 <br />