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STATE OF CALIFORNIA `. STATE WATER RESOURCES CONTROL BOARD 3W- '� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ANs "-� v� —� S!r COMPLETE THIS FORM FOR EACH FACILITY/SITE a °.�,-°-.�. MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY, ED-gJTE ONE REM Q 2 INTERIM PERMIT [_] 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA9ji FAILITY NAME t� NAME OF OPERATOR AR &ADDRESS NEAREST CROSS STREET PARCEL 0(OWIONAO z4w A4 -i9-7, CITYNAME STATE ZIP CODE SITE PHONE#WITH REA CODIj CA Ocv J ✓ BOX TO INDICATE O CORPORATION INDIVIDUAL E::]PMTNERSIOP LOCAL-AGENCY CWNrY.1GENCY O STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN *OF TANKS T SITE E.P.A. L D.#(0~)FARM 4 PROCESSOR RESERVATION O S. OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE GAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAIV �/.� � CARE OF ADDRESS INFORMATION MAIL(IN�G OR STREET ADDRESS ✓ bw bIM& D INDIVIDUAL LOCAL-AGENCY a STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION A457-1—W MAILING OR STREETbat b b01d1# 0 INDIVIDUAL LOCAL-AGENCY STATE AGENCY JJ ll Q CORPORATION PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY CITY NA ADDRESS E STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ F4]-4]-� V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II.0 III.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# vl- 1747-- LOCATION CODE -OPTIONAL CE�N§UuS TRACT# -OPTA)NAL SUPVISOR-DISTRICT CODE -OPTIONAL `G3 •Z Z-- 3Za -! 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) /06/ 1; 1;