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• STATE OFCALIFORNIA • ,,swa«g <br /> (L 1 / STATE WATER RESOURCES CONTROL BOARD ;` �`o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a <br /> COMPLETE THIS FORM FOR EACH FA /SITE �""°""'� <br /> MARK ONLY Q 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT TEMPORARY SITE CLOSURE <br /> I. FACILIT E IN ON&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ITY NAME <br /> p NAME OF OPERATOR <br /> ADDR S A_ UV I� y - <br /> 9 NEARESTCROSS STREET CEL 0(OPTIONAL) <br /> r/sop-, W <br /> (.J <br /> CITU N E <br /> S n STATE ZIP CODE q SZ.v) SI PHONE A WITH AREA CODE <br /> I/ BOX <br /> BOx C4 CA / —3(, 4 —7 <br /> TO INDICATE CORPORATION ED INDIVIDUAL 0 PARTNERSMP 0 LOCAL-AGENCY <br /> ®COFINfY" NCY QSTATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O ) GAS STAI ON 2 DISTRIBUTOR ✓ IF INDIAN ;1 OF TANKS AT SITE E.P.A. i.D.R t wim ) <br /> O TIC <br /> 3 FARM Q d PROCESSOR Q 5 OTHER OOR1ON <br /> gUSTVLANO3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE <br /> 14 f drG -?/V- 33-1 -9y3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST( PHONE 0 WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> // CAREOFADDRESS INFORMATION p <br /> OR <br /> T ADDRESS <br /> Cp, �i'i v vn ar evArvc t, cj rr C er Pts <br /> MAILING OR STREET ADDRESS ✓ bwroinalcal� Q INDIVIDUAL Q LOCAUAGENCY <br /> O CORPORATION STATE-AGENCY <br /> CITY NAMEr r7 6 7 l 3 PARTNERSHIP Q COIINrY-AGENCY I= FEDEML-AGENCY <br /> STATE ZIP CODE PHONE of WITH AREA CODE <br /> /e(ueis c� C✓9 J / S6S7 7/L/- 36q-7vS0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMgTION <br /> MAILING ORSTREETADDRESS ✓ Eo�0in0iuY INDIVIDUAL <br /> O LOCAL AGENCY OSTATE-AGENCY <br /> CITY NAME (]CORPORATION 0 PARTNERSHIP = COUNTY.AGENCY f] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 44 - <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: I.a IL a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTEDA SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION x FACILITY# <br /> m SvNR 195 <br /> t< 3 d 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOq-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 /> FORM A(9-90) FOROMM-82 <br />