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a STATE OFCAUFORNIA STATEWATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EAC C LITYIWTE MARK ONLY F__j T NEW PERMIT 0 3 RENEWAL PERMIT VV CHANGE OF INFORMATION EV 7 PERMANENTLY CLOSED SITE ONE REM [—] 2 INTERIM PERMIT Q 4 AMENDED PERMIT E a TEMPORARY SITE CLOSURE Z I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OB ACJL�rE NA OF OPERATOR he–+50 II ADDRESS_I1C.• �NEAREST CROSS STREET PARCELA(OPTIONAL) 355 ul. w L4 CITY NZ7 l „, ^ k_+bp STACA ZIP CODE SITE PHONE t WITH AREA CODE TORI✓N+DICCATEE E::] TioN INDIVNHIAL PARTNERSHIP 0 LOCAL AGENCY COUMYAWNCY STATE-AGENCY FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN SOF TAN ITE E.P.A. L D.S(opTlanae RESERVATION O 3 FARM Q 4 PROCESSOR 0 5 OTHER Ofl TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bubWieaN 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE S WITH AREA CODE III, TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNE R CARE OF ADDRESS INFORMATION MAILING ORSTREETADDRESS boa blglW D INDIVIDUAL O LOCAL-AGENCY Ij STATE- AGENCY CORPORATION PARTNERSHIP COUNMAGENCY = FEDERAL-AGENCY 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) HO F4-F4]- 3 (o 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.E:1 II.O III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR INTED a SIGNATURE) APPLICANTS TITLE DATE MONTH/OAYNEAR LOCAL AGENCY USE ONLY COUNTY# wr"'f JURISDICTION FACILITY# ® Pero 93 1149 1 si!� W � LOCATIONCqqPT7ONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Z3 180 Z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR0033AA2 FORM A(9-90)