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• STATE OF CALIFORNIA �`� STATE WATER RESOURCES CONTROL BOARD i DER ROUND STORAGE TANK PERMIT APPLICATION • FORM A .a •�•t,nOn COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY r NEW PERMIT O 7 RENEWAL PERMIT O S CHANGE OF INFORMATION a 7 PERMANENTLY LOBED SITE ONE REM 2 INTERIM PERMIT Q A AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE p I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS - NEAREST CROSS STREtT PARCEL I(OPTIONAL) CITY NAME STATE21P CODE SITE PHONE A WITH AREA CODE CA ✓ BOX TO INDCATE O CORPORATION O INDIVIDUAL O PARTNERSHIP ED LOCAt-AGENCY Q couNrYA%wY Q STATE-AGENCY FEDERAL-AGENCY DGTRICTS TYPE OF BUSINESS O M GAS STATION Q 2 DISTRIBUTORO ✓ IF INDIAN t OF TANKS AT SITE E.P.A. L D.A(gaIi ) RESERVATION a 0 FARM Q a PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: NAME(LAST,FIRST) PHONE m WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE,t WITH AREA CODE Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS / box bbtlbm O INDIVIDUAL Q LOCAL-AGENCY CD STATE.AGENCY E3 CORPORATION Q PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CIN NAME STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION• MUST BE COMPLETED NAME OF OWNER - CARE OF ADDRESS INFORMATION � q ! F n�: c MAIL ING OR STREET ADDRESS 1101 vftb Q INDIVIDUAL E:I LOCAL-AGENCY Q STATE AGENCY CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CIN NAME STATE ZIP CODE PHONE A WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739.2582 if queslions arise. TY(TK) HQ 4 4 -1 III I I I V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YFAR LOCAL AGENCY USE ONLY COUNTY M JURISDICTKA K FACILITY K r � OCC ff0 LOCATION CGDE -OPTIONAL CENSUSTMCTs -OPTIONAL SUPVIBOR-DISTRICT CODE -OPTIONAL a S THIS FORM MUST EE AC:.CMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. n FORM3A R2 FORM A(9-90) `N 3 _ �i