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• • E60VR f4 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A u; <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO RE <br /> ONE ITEM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION III ADDRESS•(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME / NAMEOFOPERATOR <br /> Ow q O✓ <br /> ADDRESS NEAREST CROSSSTREET PARCEL#(OPTIONAL) <br /> o 3,LS©A 51r- <br /> CITYNAME / STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> �,T r9 caAA 36 z-W-cr70Y <br /> ✓ <br /> Box <br /> TOINOICATE RPORATION O INDIVIDUAL =PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 3 GAS STATION O 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplional) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) t II PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ✓l 0✓1 dOh✓t O �1S- 6 S <br /> NIGHT NAME(LAS/T,FIRST) PHONE#WITH AREA CODE / NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> N /A 41 C'f(L 3Z�-Pfb� <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> IO✓I a <br /> MAILING OR BEET DRESS ✓ boxblMkab 0 INDIVIDUAL � LOCAL-AGENCY O STATE-AGENCY <br /> Q �� ` 4 APORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATFr ZIP /5iOODE 707 -79145_ <br /> Ill. <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) (� ,�/7/ !� <br /> NAME OF OWN CARE OF ADDRESS INFORMATION <br /> MAILING OR STR R122 r� ,—✓,box binAkw INDIVIDUAL 0LOCAL-AGENCY E71STATE-AGENCY <br /> d L2 c. rvMTION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMEe STATE ZIP CODE PHO E#WITH AREA CODE <br /> rjeAG�,rti Cti 1 rfe/5/v -707 -rV5-a'71 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 2 I Ll I 9 6 07 <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: L O II.O III.E�— <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# CV$'f0 Ftp/ <br /> © � <br /> LOCATION CODE -TIT NAL CENSUS TRACT# -OPTIONAL <br /> LOCATION SUPVISOR-DISTRICT CODE -OPTIONAL <br /> �/ 3 z 6 -3-26-fz <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 /> FOR0N3A-R2 <br /> FORM A(9-90) <br />