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'SSOUN CB STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD sy o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A O N COMPLETE THIS FORM FOR EACH FACILITY/SRE Ix MARK ONLY T NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ONE ITEM 0 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAqp FACILITY NAME NAME OF OPERATOR -O nas A S NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY, A `✓ STATE jp T TEZIP A3 SITE PHONE#WITH AREA CODE CA P I/ Box TOINDICATE O CORPORATION D INDIVIDUAL = PARTNERSHIP LOCAL AGENCY D COUNTY-AGENCY STATE AGENCY M FEDEMLAGENCY DISTRICTS TYPE OF BUSINESS 0 T GAS STATION 0 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TAN SITE E.P.A. I.D.#(nptkvw RESERVATION Q 3 FARM Q # PROCESSOR Q 5 OTHER RESERVATION EMERGENCY CDNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE GAYS: NAME(LAST,FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 71 ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS `�hoxb MBCY� 0 INDIVIDUAL 0 LOCAL AGENCY Q STATEAGENCY O CORPORA ON 0 PARTNERSHIP ED COUNrYAGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS bos bintlkN E::] INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY CORPORATION O PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY CITY NAME 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) HO 4 4 -1 01-311-12- V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II,O III.O 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 MONTHDAYNEAR LOCAL AGENCY USE ONLY COUNTY# �_ JURISDICTION# FACILITY It 5R Viivc-6?'y 1 1 10 ,I2y1� LOCATION 001OPTIONAL CENSUS TMCT# -OPiIQNAL SUPVISOR-DISTRICT CODE -OPTNNUL 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) FO 3A-R2