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y unces <br /> STATE OF CALIFORNIAEC <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FdIMA 5 199 <br /> kNVIRONMENTAL HE <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .o� <br /> fif���ViF�ca <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SfTE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L/ <br /> � I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D A 0 FACILITY NAME NAME OF OPE ATOR <br /> ADD SS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> V SoS 1vL•T d 94 <br /> CITY NAME STATE ZIP C DE SITE PHONE:1 WITH AR A CODE <br /> CA S 2d Z_3y-7W <br /> ✓ <br /> BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL (] PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR / IF INDIAN x OF TANKS AT SITE E.P.A. I.D.x(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR a 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> C DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(L ST,FIRST) ' PHONE*WITH AREA CODE <br /> Azle, —l1 <br /> 2 <br /> NIGHTS: NAMEL T,FIRST) ' 1i PHONE WITH AREA CODE NIGHIA: NAME(L ;r AST,FIRST) PHONE WITH AREA CODE <br /> �` ,e /y -G �Z C « nd S,2 -6, 71 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bo indicate INDIVIDUAL LOCAL-AGENCY <br /> � D STATE-AGENCY <br /> ORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME QWN R CARE OF ADDRESS INFORMATION <br /> MAILI R STREfri ADDRESS ✓ box bindicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> YT <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CO E PHONE 11 WITH AREA CODE <br /> ?CIO <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 44 -10 1.2 ®f3U <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.0 II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRWYD&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY,9E ONLY <br /> COUNTY# JURISDICTION# FACILITY# Qj S 1M�- <br /> 31 I I I3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> OS <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 /> FORM A(9-90) <br />