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�6oUACes <br /> STATE OF CALIFORNIA A f . <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �a '�o <br /> ;, z•r , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION E::] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILE NAME NAME OF OPER TOR <br /> J G4.5 GrUC€R I D016,✓ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> To c.K -Cea1 CA zo 6 -03� <br /> ✓ Box <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS [fT I GAS STATION 2 DISTRIBUTORQ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RES✓ERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAY : NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 01hons �Y- -G 0,:; <br /> G O✓N S �-a�l— —D DS <br /> NIGHTS: NAME(LAST, IRST) PHONE#VVI I H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> sz 6 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ha ac�r+ tL rn� I� k ��Idoc,v U h�iU <br /> MAILING OR STREET ADDRESS ✓ box lo indicate ED INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> –i"�Pv- Q CORPORATION U PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY AME STATE ZIP CODE _TiPHONE#WITH AREA CODE <br /> C''o i�) a$7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> AME OF OWNER CARE F ADDRESS INFORMATION <br /> ( 00/U 0 Mk IL K u IWOO Aj 07% M IL/ <br /> MAILINd OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 1-70 5 C r-t-e r— Q CORPORATION �RTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> C_k To Aj 1c GS 20 6 -14 -0 3 01 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4 74 - r? <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.R!lr II.O 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) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> or #W/ ow`�CtjW <br /> - ?Wr�Q �Z -�- Q <br /> LOCAL AGENCY USE ONLY A 3 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIOCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE ZONAL <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(9-90) Ar <br />