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t10VN fy <br /> c�4 <br /> STATE OF CAUFORNIA 'o <br /> STATE WATER RESOURCES CONTROL BOARD Wy`P y S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A <br /> COMPLETE THIS FORM FOR EACH PACILITYISITE <br /> MARK ONLY 0 I NEW PERMIT 3 RENEWAL PER 5 CHANGE OF INFORMATION 7 PERMANENTLY CL DSO/ <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) oPEaATOR <br /> OBAOR FACILITY NAME ` L <br /> `G� JC:1 rTIN S n I_ PARCELO(OPrI0NA4 <br /> ADDRESS / G NEAREST CROSS STREET <br /> 5 4.In C e bl <br /> STATE ZIP CODE S PHONE#WITH AREA CODE <br /> CITY NAME <br /> 9 74-el-3 J <br /> ✓ PoxORPORATION Q INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY Q FEDERALAGENCY <br /> TOINDICATE DISTRICTS <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(cplkn4# <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOfl 0 RESERVATION % <br /> 0 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•option jI <br /> PHONE x WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> DAYS: NAME( T,FIRST) yy� // 1 300 7� <br /> 4�l 1^�- Z�/ PHONE#WITHA'EA CODE <br /> NIGHTS: NAME(LAS IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. P PERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NA <br /> Lec )e f0/4 ✓ box biMiome <br /> MAILING OR STREET yADDRESS (] INDIVIDUAL O LOCAL FEDERAGENCY <br /> l l j I�c'r S`c�� ��/'• CORPORATION Q PARTNERSHIP COUNTYAGENCY OFEDERAL-AGENCY <br /> STATE ZIP C( 'I PHONE#WITH AREACODE <br /> CITY NAME <br /> 1L,'.ro <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ bot biMiWe INDIVIDUAL LOCAL-AGENCY STATEAGENCY <br /> MAILING OR STREET ADDRESS <br /> Q CORPORATION Q PARTNERSHIP COUNTY AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE S WITH AREA CODE <br /> CITY NAME <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - D Z Z <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.E II.� 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 8 SIGNATURE) <br /> APPLICANTS TITLE DATE MONTHIDAYNEAA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTION# FACILITY# kNNI FI <br /> SUPVISOR-DISTRICT CODE OPTIONAL b <br /> LOCATION CODE OPTIONAL CENSUS1 ACT# -OPTIONAL I /J <br /> THIS FORM MUST BE E ACCOMOANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.RRz <br /> FORM A(490) • <br /> i <br />