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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A D COMPLETE THIS FORM FOR EACH FACILITYISRE MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION 7 PERMANEWLY CLOSED SITE ONE REM O 2 INTERIM PERMIT E�] A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEU(OWIDNAD CITY NAME STATE 2W CODEI SITE PHONE• STH AREA CODE SToc. l CA �j Zo I/ Box Zo9) 6Z' D(��O TOINDICATE Lf CoRPmam D INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY D COUNTYAGENCY D STATE AGENCY O FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O I GAS STATION Q : DISTRIBUTOR Q ✓ IF INDIAN s OF TANKS AT SITE E.P.A L D.s IapeaW) RESERVATION O 3 FARM O I PROCESSOR 5 OTHER Ofl TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE s TH AREA CODE DAYS: NAME MST,FIRST) PHONE s WITH AREA CODE ko� �i l <zon) �Z— NIGHTS: NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION - MAILING OR STREETrADDRESS {. ✓ kaN O INDIVIDUAL LOCAL.AGBICY STATE-AGENCY CORPORATION PARTNERSHIP COUNTYAGENCY FEDEMLAGENCY CITY NAME�G STATE ZIP25� !� CODEffIONE FaWI z1D O6 III. TANK OWNER INFORMATION•(MUST BE COMPLETED) M NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS box bkdb INDIVIDUAL QLOCAL-AGENCY OSTATEAGENCY I�CORPORATION D PARTNERSHIP COUNTYAGENCY 0 FEDERAAGENCY CITY NAME BTATE LP CODE PHONE i 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 II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II. III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY CWNITY# RISD 10 FACILITY# ae, I l I l I 1181 /+ior. ?— LOCATION CODE -OPTIONAL CENSU TRACTi- TiONAL SUPVISOR-DISTRICT CODE -OPTIONAL O r 7i7j 21 R — THIS FORM Ml)ST BE ACCOMPAWD B AT LEAST(G)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, a FORM A(1�90) FORMA-R2 011