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,OUR <br />OCp <br />STATE OF CALIFORNIA Ac a <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />e o' <br />• Cil If011 N� <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a NTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I / <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />NAME OF OPERATOR <br />Yom <br />milk Vic. <br />e+�ko�l etAanAce <br />fdo0 - -7 Id - 310 1 <br />ADDRESS <br />iQ(00 V�. <br />( _ S <br />NIGHTS: NAME (LAST, FIRST) <br />NEAREST CROSS STREET <br />C y-,rek\ %-Vo\`04 <br />PARCEL 0 (OPTIONAL) <br />CITY NAME <br />CJAW'170h�Au&.sjL <br />00 - -1 -11 - 24 <br />STATE <br />ZIP CODESITE <br />PHONE # WITH AREA CODE <br />-Fra-c <br />CA <br />'IS 3-7(v <br />TOINDI ATE CORPORATION INDIVIDUAL = PARTNERSHIP <br />O LOCAL -AGENCY (] COUNTY -AGENCY (] STATE -AGENCY O FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS{ 1 GAS STATION 2 DISTRIBUTOR <br />INDIAN <br />0 <br /># OF TANKS AT SITE <br />E. P. A. 1. D. # (optional) <br />3 FARM <br />0 4 PROCESSOR 0 5 OTHER <br />R SEIF R <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />Takavi <br />t a 8�� - <br />e+�ko�l etAanAce <br />fdo0 - -7 Id - 310 1 <br />NIGHTS: NAME (LAtT, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />PHONE #WITH AREA CODE <br />s- 8L�;. - 105-0 <br />STATEZIP <br />CA. <br />CJAW'170h�Au&.sjL <br />00 - -1 -11 - 24 <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />aev'r-vvN_ <br />MA <br />CARE OF ADDRESS INFORMATION <br />01' v-0 l,��A 1-xc . <br />MAILINGORSTREET ADDRESS <br />PQ, SooCORPORATION <br />✓ box to indicate 0 INDIVIDUAL <br />PARTNERSHIP <br />E::] LOCAL -AGENCY 0 STATE -AGENCY <br />= COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME <br />Sati, <br />'P_avtGvj <br />TATE <br />CA. <br />ZIP CODE <br />I q45 > <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />PHONE #WITH AREA CODE <br />s- 8L�;. - 105-0 <br />III. TANK OWNER INFORMATION. (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />DATE MONTWDAYNEAR <br />01' v-0 l,��A 1-xc . <br />W + <br />8 d ) s -C't <br />MAILING OR STREET ADDRESS <br />-?m SOOLf <br />✓ box to indicate 0 INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />F©- Y_ <br />CORPORATION Q PARTNERSHIP <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />So,... �aw�ol. CA <br />STATEZIP <br />CA. <br />CODE <br />4-fs8; <br />PHONE # WITH AREA CODE <br />415 s4X! Yosa <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (TK) HQ 4 4 -101 S1 (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 BD FOR LEGAL NOTIFICATIONS AND BILLING: I. a II. E:1 <br />THIS FORM HAS BE&t rr RPCE; UN ER Py, LTY VidERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) <br />APPLICANTS TITLE <br />DATE MONTWDAYNEAR <br />v)� 6T_ ,oc W� <br />W + <br />8 d ) s -C't <br />LOCAL AGENCY USE ONLY <br />COUUNNTYYY # ( JURISDICTION # FA CITY # <br />5- 3 <br />LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIO <br />Z 7- —7,7-11 <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 />