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esouRCes <br /> STATE OF CALIFORNIA �: <br /> STATE WATER RESOURCES CONTROL BOARD a . <br /> UNDERGROUND STORAGE T�NKPE, MIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `•�,F°^N <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMI ' 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERM] ";f a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> tck Jeg Aalfir-wj <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 10_-3.O S. 0 i ,Mar tJ 93 fi <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> joco N CAI/ BOX <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optimal) <br /> IF <br /> Q 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 /> J ,201— -C'73 1 dor1<' rs _. E . son <br /> NI 'TS: 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 Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> c1 56 r7 N T 7"/< Q CORPORATION Q PARTNERSHIP QCOUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME �aQSTATE ZIP CODE PHONE#WITH AREA CODE <br /> �' /�S3 / <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF DORESS INFORMATIO <br /> (Py Ir[/ D <br /> MA LI_OR STREET AD RE ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Gx 50�7-'l 5 Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> ; - f 7--l-53 12 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-F4-1-1 I I I <br /> V. <br /> 4 - <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 it.[—I 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> S7 � 7T ]0 �(CKS 7 C> <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> .32 157 <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 /> ��� <br />