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�so�^ ee STATE OF CALIFORNIA ^e e% STATE WATER RESOURCES CONTROL BOARD i 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� yj COMPLETE THIS FORM FOR EAC FACILITY/SITE 1eOe� MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SRE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME A NAMEOFOPERATOR ADORES ovnd �//y1C�• NpESTCR SS TREET PARCEL#(OPrIONAL) -AVS. �ZJ1 I�0 V'gt�f CITU N EOCK STATE ZINE0 AREACODE pDITYCA D WITH TINCAE l�CORPORATION INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTYAGENCY STATE-AGENCY FEDEML-AGENCY DISTRICTS TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR / ❑ RE/ IF INDIAN A OF TANKS T SITE E.P.A. I.D.»f4VIMal) E7) 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS C ow-5 O EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE A WITH AREA CODE NMeHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ hD(bindn'* O INDIVIDUAL LOCAL-AGENCY O STATE- AGENCY CORPORATION PARTNERSHIP O COUNTYAGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS bmbkdioia INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY CORPORATION PARTNERSHIP COUNTYAGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. TY(TK) HO 4 4 -FT—T—FT—F V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PH INTER A SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY .,�L COUNTY N HR 4ISDRT 6N p_„&)ejF�S FACILITY# am 7"/ kE ! Z V LOCATION CODE Ae OPTIONAL CENSUS TRA t��NAL SUPVISOR-DISTRICT CODE -OPTIONAL q/ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(9 90) FORn3AA RR2