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PEcou° ey STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD '0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A •�� ° e '`P I.. o COMPLETE THIS FORM FOR EACH FACILITWSITE °•��.aP.,.. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM F72 INTERIM PERMIT ❑ d AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAM; itC �a`/ ��G A1/ NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCELS(OPTIONAL) CITY NAME r STATE ZIP CODE 36 SITE PHONE 0 WITH AREA CODE CAI/ BOX TO INDICATE CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY ED OOUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR Q RESERVATION✓ IF INDIAN SOF TANKS AT SITE E.P.A. I.D.S(optional) ❑ 3 FARM ❑ 6 PROCESSOR �6�HER OR TRUST LANDS T.J EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAMECARE OF ADDRESS INFORMATION a / MAILING OR STRE TAD ESS / ✓box bIWIca [�1NONDUAL = LOCAL-AGENCY =STATE-AGENCY 6 (]CORPORATION = PARTNERSHIP =COUNTY AGENCY = FEDERAL-AGENCY CITY NAMESTAT 21P�`�� 6 PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) (� l NAME OF OWNER CARE OF ADDRESS INFORMATION SR/t4C MAILING OR STREET ADDRESS box bbEbals D INDIVIDUAL LOCAL-AGENCY O STATE AGENCY 1�CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDEIMLAGENCY CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 - d Z O 1-71 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.❑ II.�I.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY ®# JURISDICTION# FACI� {Th A- `6 33 LOCATION CODE -OPTIONAL CENSUUSRACT# -OTIONAL SUPVISOR-DIS;K:T CODE-OPTIONAL THIS FORM MUST CBE/ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOROGMAA2 FORM A(9-9G)