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0 STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SrTE <br /> MARK ONLY i NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [-] T PERMANENTLY C SITE <br /> E:]ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O g TEMPORARY SITE CLOSURE y r/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / CJ <br /> 03 FACILITY NAME <br /> NAME OF OPERATOR <br /> AD RE <br /> NEAF]E$TCRO STREET , PARCEL#(OFTIONAU <br /> CITY NAME l/(�/ <br /> C: STATE ZI DE SI PHONE#WITH AREA CODE <br /> v BOX CA a. ® (� <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY ATE-AGENCY ' <br /> DISTRICTSL7 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION Q2 DISTRIBUTOR '/ IF <br /> IF INDIAN x OF TANKS AT SITE E.P.A. I.D.x/N'Hianap <br /> a 3 FARM O x PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) , PHON x WITH AREA CODE <br /> ` D&Vf k a a4 yp DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MU T BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkata <br /> Q INDIVIDUAL (] LOCAL-AGENCY El STATE-AGENCY <br /> CITY NAME <br /> ______ CORPORATION 0 PARTNERSHIP ED COUNTY-AGENCY I= FEDERAL-AGENCY <br /> - STATE ZIP CODE <br /> PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION. MUST BE CO LETED) <br /> NAME OF OWNER CARE OF ADORES.INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbiMk#x <br /> 0 INDIVIDUAL O LOCALAGENCY 7!STATE-AGENCY <br /> CITY NAME 0 CORPORATION = PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOU T NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ K4]_�� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notifi ion 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 NOT (CATIONS AND BILLING: LE] ".-0m. <br /> a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN^Y# JURISDICTION# FACILITY#E-= <br /> j <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT#-OPTAL SUPVISOR- <br /> DISTRICT CODE -OPTIONAL <br /> # .30g, Y <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 /> FOROMA R2 <br /> ` ' <br />