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ts.UR C <br /> STATE OF CALIFORNIA • Mr p ."' �O <br /> STATE WATER RESOURCES CONTROL BOARD s" , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> • C�l,fon N.�. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SRE <br /> MARK ONLY 12r, NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFACILITY AM�-Sevvl <br /> NAMEOPOPER TOR <br /> , <br /> ADDRESS�y � ' L� � � NEp,� TCROSSSTR� PARCE k(OPr <br /> J (fatahlA <br /> til <br /> CI ME STATE j ZIP CODE SITE PHON #WITH AREA CODE <br /> CA 2 2 -Q <br /> ✓ BOX <br /> TO INDICATE EWCORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 0 2 DISTRIBUTOR Q ,/ IF INDIAN #OF TANKS AT E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ��� H NE#WITH AREA CODE DAVE: NAME(LAST,FIRST) Pt1 j #WITH AREA -trI <br /> ill <br /> NIGHT . NAME(LAS ,FIRS , PHONE#WITH AREA COPE NI TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r - ( 6 &_ <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> Nn/t ,l'i r , CARE OF ADDRESS INFORMATION <br /> MAILI EE AD <br /> OR ST DRF ✓ box ID indicate <br /> 9 Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> �, to � O EP ORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI E STATE ZIP OD PONE#XVITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA F OW yE /-�.- . 1 01 / CARE OF ADDRESS INFORMATION <br /> L/J fl' <br /> MAILING R STREET AD ESS y� ✓ box Io indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> at l �F L}SvoRPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI A E STATE ZI CODE PHONE#WITH AREA CODE <br /> m VCD r 2 1;;, -if)I cid <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 44 -� 1 <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: <br /> THIS FORM HAS BEEN COMPLETPOUNDERPENA Y OF PER,JIURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT ;NTS NAME(PRINTED&SIGNA R APPLICANTS TITLE DATEW Y/YEAR <br /> t"mi <br /> I C z S <br /> LOCAL AGENCY USE ONLY [z +- <br /> COLINT Y# JURISDICTION# FACILITY# <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 SITE INFORMATION ONLY. <br /> FORMA(9-90) <br /> FOR0033A-R2 <br />