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• STATE OF CALIFORNIA • eco°"o. <br /> STATE WATER RESOURCES CONTROL BOARD �� �_� �o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACIUTYISITE <br /> MARK ONLY ❑ 3 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 <br /> DBA OR FACILITY NAME — NAME FOPERATOR <br /> n_k oo eN <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTIONAU <br /> 016 Ma r I KI©sem <br /> CITY NAME <br /> c� STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> -10 ON CA 952Ob 62— o <br /> ✓ <br /> BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY <br /> DISTRICTS O FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 3 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 1 OF TANKS AT SITE F.—P.-A. L D.#(gwma# <br /> RESERVATION 1/ <br /> Q 3 FARM O d PROCESSOR 5 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 /> o�ker. Joe k - I e 2cxi- sz- 2 OF3 <br /> NIGHS: NAME( ,FIRST) PHONE#WITH AflEA CODE NIGHTS: NAME(LAS ,FlRST) PHONE#WITH AREA CODE <br /> oAkc' i ccl zn — 9c7 30 C <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �cq3 <br /> MAILING OR STREET ADDRESS ✓bOtbWicala 0INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME gEOWNER CARE OF ADDRESS INFORMATION <br /> e. e7s <br /> MAILING OR STREET ADDRESS ✓ Eox uagKate O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP D COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATE 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) HQ4 4 -L_LL I I I I <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ III.❑ <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) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> r 6 kcoxayo <br /> LOCATION CODE -OPTIONAL CENSUSSIF C��TONAL 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 /> F RM A(5.90) \ FOR0033AA2 V <br /> i <br />