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Uvwx, 1 tz S-A 0 I STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD sy UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y; C, COMPLETE THIS FORM FOR EACH FACILITYISfTE MARK ONLY ❑ r NEW PERMIT ❑ 3 RENEWAL PERMIT x 5 CHANGE OF INFORMATION O 7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE D�+ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME NAMEOFOPERATOR ADORES _ NEAfl TCROSSSTR PARCEL#(OPFIONAW 1 CITY-NAME STATE rjIP CODE SIDE PHO t WITH AREA CODE CA l/1vc�p TOINDCATE CORPORATION O INDIVIDUAL D PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY D STATEAGENCY 0 FEDERKAGENCY TRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN RESERVATION t OF TANKS AT SITE I E.P.A. I.D.t(apATell ❑ 3 FARM ❑ 4 PROCESSOR /5OTHER OR TRUST LANDS EMERGENCY ObiffACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST( PHONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE - NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE II. PROPERTY OWNER INFORMATIO MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box blydbaW Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY =CORPORATION PARTNERSHIP COUKrV-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE 111. TANK OWNER INFORMATION- MUST BE COM ETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bNMbate O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY f�CORPORATION 0 PARTNERSHIP COuRruSENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -'0[p +j jq5 Y] V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless)6x I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND 13ILLNG: I. IL[7] 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# .F3ff LOCATIONCOOE -CPTAONAL CENSUS TRACTi-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL F. A 3 . 80' -350' D� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS 1S A CHANGE OF SITE INFORMATION ONLY. FORMA-112 FORM (390) "/��/1 �/