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�youRces <br /> STATE OF CALIFORNIA ��P '-••" cO? <br /> STATE WATER RESOURCES CONTROL BOARD a` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> • C��IFOR N', <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MARK ONLYNEW PERMIT 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE v/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> c)(n;;FJ� Fz1lIGc�'TF�T'1 C 3?! �{Z�C (CE7 �✓�L._L. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2'7G u�dN �'YGLIJ6 Il .vv. RYt�. A.,� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 9Z_i94 <br /> TOINDIC TE [j C<CRPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS LX t GAS STATION a 2 DISTRIBUTOR IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RES✓ERVATION 'w <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDSr-�����Z� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e*L.•L- V-jt ••I(!ES cWe;>-1 r)W=f-471V--HG - F 7 73g <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G M.bt �iG'P-9x12- � TcHC�Ti�e <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Enxxc>i4 cOr--lFxq-XY <br /> MAILING OR STREET ADDRESS ✓bo b Indicate E�:] INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> ?i �•�,,,� ©� vzf>. CORPORATION Q PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> G�Nu�FZfl GO 4►5 8-1SZ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - C;Q Z 8 5 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' checked <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EE 11. 11 <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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 53 <br /> LOCATION Co -OPTIONAL CENSUS TRACT# _OPT AL 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 /> FOR0033A-R2 <br /> FORMA(9-90) / _ <br />