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�SOURCCS <br /> f` tuitt. Cp <br /> STATE OF CALIFORNIA M1� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNCf RGROUND STORAGE TANK PERMIT APPLICATION- FORMA Q <br /> l / �'tiFon N`�•o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ® I PERMIT F__] 3 RENEWAL PERMIT F__] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 16D <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Ab v <br /> CITY NAMEP STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TOINDIC TE IQ CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS A6 1 GAS STATION O 2 DISTRIBUTORQ ,' IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM a 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 AST,FIRST) PHONE#WITH AREA CODE <br /> ,r <br /> NIGHTS: NAME(LAST,FIRS PHO E#WITH AREA CODE NIGHTS: NAME(LAST,FIRS[) PHONE#WITH AREA CODE <br /> TOW (� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR TREETADDRESS ✓ box bindicate 2Y INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME <br /> Q�p 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 bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 K4 - <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.M it.D III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPA S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> �F o 3 a 43 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION C OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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) 0 <br /> FOR0033A-R2 <br />