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souRces <br /> STATE OF CALIFORNIAe+G `0t <br /> STATE WATER RESOURCES CONTROL BOARD 3� 'y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 0 <br /> C�(IFON N�f <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY l NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> ONE ITEM F__1 2 INTERIM PERMIT 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE V <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) O <br /> DBA OR FACILITY ME � NAME OF OPERATOR <br /> ADDR�ESS Q NEESTCROSS STREET PARCEL N(OPiIONAL) <br /> If <br /> CITYNAME STACEAK� ZIP CODE SITE PHO E#WITH AREA CODE <br /> [ r✓ ? I A. <br /> ✓ Box <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN I#OF TAN1S AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION /_/F� <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OAY$: NAME(LAST,FIRST) l� PHONE WITH ARE+CODE DAYS: NAME(LAST,FIRST) i� � O�#�WITH AREA CODE <br /> NIIGG{HTS: NAME(L T, IRST) PHONE IfWITH AREA CODE NIGHTS: N ME( T,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED _ <br /> NAM ARE O ADDRESS W1 F RMATION � ��3.� G©o <br /> _ Cy/'q� W W r2iv�� v 1�• 1 <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> D �I G 4';j <br /> INDIVIDUAL LOCAL-AGENCY _� STATE-AGENCY <br /> ( <br /> j .- I� Ee'CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY AME / STATE ZIP CODE PHONE#W TH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME4F OWN R CARE OF ADDRESS INFO MATIO <br /> I p I�JIL�O1� G✓Te , -1 o0 <br /> MAILING OR STREETi R, E$S , �O ✓ box birbicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> I(�� I jv�wrjvv� P `4TrCORPORATION = PARTNERSHIP 0 COUNTY-AGENCY [:71 FEDERAL-AGENCY <br /> CITY N2HC, / . STA_E_ Z��V C FIS✓ �RE�ODEI <br /> IV. BOARD CF EQUALIZITICN UST STORAGE FEF ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HC F4-[4]- C) 4f -� q <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.[:] 11.[:7] III.[JI <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&SIC 4ATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> 4-7-4-)I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> a4 <br /> a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 SffE IMATION ONLY. <br /> FORM A(9-90) <br /> �� FOR0033A-R2 <br />