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R . STATE OF CALIFORNIA - s, STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ae COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE L I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR J L i v�cic � ADDRESS NEAREST CROSS STREET PARCEL#(OPfIONAL) lZol 171 u.✓c7rG� �' CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE CA Box TO INDICATE CORPORATION NUIVIWAL (]PARTNERSHIP 0 LOCAL-AGENCY��ENCY Q COUNIVAGENCY 0 STATE-AGENCY 0 FEDERALAGENCY DISTTYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN 1 OF TANKS AT SITE E.P-A. I.D.i(OP60W RESERVATION ❑ 3 FARM ❑ ! PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ batik'IM 0INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP I]CDUNTYAGENCY 0 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE III. TANK OWNER INFORMATION- (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS V bft l)W cau O INDIVIDUAL Q LOCAL AGENCY D STAT6AGBICY 0 CORPORATION 0 PARTNERSHIP O COUNrY-AGENCY 0 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 F41-4]- 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: L❑ 11.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED!SIONATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTYx JURISDICTION 0 FACILITY R 51-=77C/ IK0)� LOCATIONCODE -OPTpNAL CENSUS TRI-OPTIONAL ISOR-DISTRICT CODE •OPTN)NAL a3 SUPV3a-N CG) I°fit, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SUE INFORMATION ONLY. FORM A(490) FOR0033A4