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kt) �\h� <br /> • t`ou e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD y 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> a 1 <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONa 7 NTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> row HSA 14.1c- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> �gfoO W. , 4� Cor,rek\ 0,4 <br /> CITY NAME STATE JZIP CODE SITE PHONE#WITH AREA CODE <br /> 1 CAv Box <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS {�[ 1 GAS STATION Q 2 DISTRIBUTOR Q RE./ IF INDIAN SERVATION <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Txk r• e. 415 $q;-- e11lro1j e"AV_.-_ Soo - _T"7 a -33,01 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE,I <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,r0 V1 {JLS <br /> MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL QLOCAL-AGENCY Q STATE-AGENCY <br /> Q. St70 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME tTATE ZIP CODE PHONE#WITH AREA CODE <br /> SCS �Awt ovi CA Gt �8 3 (kg - O SO <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> (2 roti (,SSA 1►1C . <br /> MAILING OR STREET ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> T Q, x SOO� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S0" CA. Cp, I ct IXC S8; 415-- oSa <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -[ol sl j Ig f 3 <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 SHOUL B D FOR LEGAL NOTIFICATIONS AND BILLING: I.ED [I.E] III. <br /> THIS FORM HAS BE UN ER P LTYERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> i <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE T ATE MONTHIDAYNEAV1p 6r_ moA Ag•- S_CFF <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FATY# <br /> i✓/A/ 5 ...9 4//� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL ISOR.DISTRICT CODE -OPTION — <br /> y SUPV-Z _2.7-gi <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 />