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�SCURCPS <br /> STATE OF CALIFORNIA t P c° <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s� <br /> C�[1rON N,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE 0/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /LltSG Issue Iperm <br /> (f <br /> DBA.DR FACT ITY N ME NAME OF OPERATOR <br /> CAi eO <br /> AD ESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY N ME / STATE ZIP Szw- SITE PHONE#WITH AREA CODE <br /> ZI&I(^C iLr CA <br /> ✓ BCORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY <br /> TO INDICATE � FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 3 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL <br /> LOCAL-AGENCY 0STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� 2 y <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 II.F7 III.0 <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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# C_6 JURISDICTION# FACILITY# <br /> LOCATION C E -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> c�'C-) 3z <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) FOR0033A-R2 <br />