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°yypw ea STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° v; • I�p1�Y� COMPLETE THIS FORM FOR EACHfi&LITYISRE MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACILITY NAME NAME OF OPERATOR ADDRESS 3 NEAREST CROSS STREET PARCEL#(OPTIONAL) 1 £ � CITY NAME Lcsuu. �7 STATE ZIP CODE SITE PHONE t WITH AREA CODE Box (r/OYY//� CA 37 1 TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY D STATE-AGENCY O FEDERAL-AGENCY DSTWCTS TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(opfgv!) RESERVATION Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST SERVI LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NFrgJ O - �O 2 NIGHTS:NAME(LAST, IgST) P ONE#WRH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION rJAAIu� NUNF'~N MAILING OR STREET ADDRESS ,./, ✓6OabMkm O INDIVIDUAL 0 LOCALAGENCY 0 STATE-AGENCY O 0 I I�.Q•�_. D CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME _ STATE ZIP CODE PHONE#WITH AREA CODE Is . C/+ q 142-3 15 922---6ZZ(4 III. TANK OWNER INFORMATION-(MUST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box mVd u INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCYCITY 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) HQ 4 4 -� V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O 1 III.E THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY I�— COUNTY It JURISDICTION# FACIL17Y Y ® IGa kj CL3 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTAONAL SUPVISOR-DISTRICT CODE - OPTICIAUL � THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE 0 RE INFORI'MATIO6 ONLY. �A FORM A(9.90) FOROMMA2 !L.