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STATE OFCAUFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACIUTYIBRE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> THE EL DORADO SENIOR APAR'imwrs CAREFITS HOMES <br /> AD1€00 S. EL DORADO STREET NEARESTr.RMT§ffiEE T PARCEL 0(OPTIONAL) <br /> CIN N/O STATE �•11''HH ZZIIPUUCODDDE11'1L�i SITE PHONE s WITH AREA CODE <br /> � CA 95206 <br /> TO DICCAATE D CORPORATION INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY Q COUNTYAGENCY <br /> 0STATE-AGENCY 0 FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN 10 OF TANKS AT SITE E.P.A. I.D.R OpMaw <br /> Q 3 FARM O 4 PROCESSOR 2MKOTHER OR TTRUSTTVATIONLANDS 5 CAC000654520 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHON X AREA CODE <br /> HULL, TERRY (209) 477-8200 HOLMAN, LYNN (209) 477—Y216 <br /> NIGHTS: NAME(LAST,FIRST) PHONES WITH AgEA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITHAREA CODE <br /> HULL, TERRY (209) 473-4024 HOLMAN, LYNN (209) 952-1061 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME <br /> CARE <br /> CITY OF OF ADDRESS INFORMATION <br /> STOC[Ci1�N <br /> MAILING OR.... ADDRESS ✓taa b 4dicaN <br /> 425 N. EL DORADO STREET INDIVIDUALQ LOCAL AGENCY O STATE-AGENCY <br /> CIN NAME CORPORATION 0 PARTNERSHIP E:1 COUNTYAGENCY FEDERAL-AGENCY <br /> STOCKTON STATE ZIP CODE PHONE X WITH AREA CODE <br /> CA 95202 (209) 944-8212 <br /> III. TANK OWNER INFORMATION. MUST BE COMPLETED <br /> NANE�OFpW <br /> .S�iHMN' AS ABOVE <br /> CARE OF ADDRESS INFORMATN)N <br /> MAILING OR STREET ADDRESS Em b IrAkau <br /> INDIVIDUAL 0LOCAL-AGENCY Q$TATE-AGENCY <br /> CIN NAME O CORPORATION 0 PARTNERSHIP = COUNryAGENCY Q FEDERALAGENCY <br /> STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO [4-T-4] 0 3 3 6 8 8 <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 /> ilk--u' I O 111 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME PRINTEDAS A APPLICgNTS TITLE <br /> DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY s JURISDICTION k <br /> E LDoR I"( b <br /> LOCATIONCODE -OPTIONAL CENSUS TRACTS -OP710NAL SUPVISOR-DISTRICT CODE -OPTIONAL - <br /> z3. a 3 Zr i 2 <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 /> FORM A(9.90) <br /> FDIi00J1AA2 <br />