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� q STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `� v Cd. . COMPLETE THIS FORM FOR EACH F CILTTYISITE - MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT y CHANGE OF INFORMATION 7 PERM Y CLOSED SITE ONE REM 0 2 INTERIM PERMIT Q A AMENDED PERMIT C] a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCEL•(OPrONAU Ila CITU NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE CA ys z-o ✓ BOX TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 CWNTY#GENCY 0 STATE-AGENCY 0 FFAERALAMNCY DISTRICTS TYPE OF BUSINESS Q T GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.0.a Iopf j Q 7 FARM ! PROCESSOR M11 OTHER OR RESERVATION TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRS1) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE N II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0 INDIVIDUAL LOCAL AGENCY 0 STATE-AGENCY S `� � box b 0 0 CORPORATION 0 PARTNERSHIP 0 COUNTY#GENCV 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS tImo aM CD INDIVIDUAL 0 LGGLL.AGBN'y 0 STATEAGENCY OCORPORATION 0 PARTNERSHIP 0 CWMfY#GENCY 0 FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cal)(916)739-2582 if questions arise. TY(TK) HQV-44 -� 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: I.[::] 11.0 Ill.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED L SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION K FACILITY 0 , L pKv II LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTA7NAL SUPVISOR•DISTRICT COOS -OPTIONAL i 3 ill THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR ANDRE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATt ONLY. FORM A(a.aq FOR0OSOA-R2