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D � • P�yp`RGes C <br /> • �� STATE OF CALIFORNIA <br /> III/// VVV STATE WATER RESOURCES CONTROL BOARD <br /> MAY 12 jg j�NDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> �j� COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK(�DCi7kAl �ERMIT p 3 RENEWAL PERMIT v i CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEEM����� [�] 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE40 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> `1"I r,� jYIU 1 rgrii<Dilgf <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> f �'� �1 • Ajj 60_q te a, <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5`M C 1<7v'I/ c CA e)5 a©5- d.2-6-4n 6- <br /> I/ <br /> ✓ BOx <br /> T0INDICATE (]CORPORATION L] INDIVIDUAL I!L PARTNERSHIP LOC DISSENCY COUNTY-AGENCY STATE-AGENCY FEDERALAGENGY <br /> TYPE OF BUSINESS �"I GASSTATION 2 DISTRIBUTOR <br /> I/ IF INDIAN #OF TANKS AT SITE E.P.A. k.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME jLAST,FIRST) PHONE#WITH AREA GOOF <br /> 19, 1 _G v,i T{�lY �a��) Z442-5-1;"15 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 9,Ce,)bra 2 <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY <br /> } / ♦ F 5 �, C]CORPORATION PARTNERSi4lP 0 COUNTY-AGENCY I] FEDERAL-AGENCY <br /> /CITY NAME /� l STATE ZIP COrDE PHONE s WITH AREA CODE <br /> C 14 7V/V. C 17J <br /> Ill. tTAK70WNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> '7-j4/-1 14 p Al -0r AoTFI— <br /> MAILING OR STREET ADDRESS box b Indicate 0 INDIVIDUAL [� LOCAL-AGENCY 0 STATE-AGENCY <br /> 17 '6 ,,IC (]CORPORATION PARTNERSHIP r__] COUNTY-AGENCY FEDERAL-AGENCY <br /> ZIP <br /> CITY NAME STATE CODE N1 PH(O�NE#WITH AREA CODE <br /> 5TC/ ' cA L <br /> 09) <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 6 _Z,3 '?71 <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 ANIS BILLING: i.a it.E] III.Il y <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 MONTHIDAYIYEAR <br /> f <br /> L")-,n P-ir "3 e 1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ) <br /> LOCATION`CODF OPTIONAL CENSUS TRACT K -OPTIONAL SUPV GOR-DISTRICT CODE -OPTIONAL <br /> SID <br /> li I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOR ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR0033A-R2 <br /> FORM A(9-90) 141-11 <br />