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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD pie t g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILTTYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ & TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 5 ioh/ viNEY�°� ADDRESS9� NEAREST CROSS STREET PARCEL#(OPTIONAL) ZIP CITY NAME !/ STATE ZIP CODE SITE PHONE i WITH AREA CODE CA 4762Z-4 ria) 365— SiW Box TO INDICATE O CORPORATION O INDIVIDUAL [_1 PARTNERSHIP O LOCALL TSENCY COUNTY-AGENCY STATE-AGENCY 0 FEDEIMLAGENCY TYPE OF BUSINESS I7 1 nec STATION Q 2 DISTRIBUTOR O ✓ INDIAN t OF TANKS AT SITE E.P.A. L D.t(apfWKq ul_�3'— RESERR VATION r FARM O 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(UST,FIRST) P ONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME `! ��v ' CARE OF ADDRESS INFORMATION 4'- tJ.1.91Xj � leF` Go MAILING OR S'TRREET RES ✓Eoa In Wbm 0INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDEMLAGENCY CITYSTATE ZIP CODE PHONE 0 WITH AREA CODE I-CZ Z 42, III. TANK OWNER INFORMATION- MUST BE COMPLETED NAME OF OWNERCARE OF ADDRESS INFORMATION G �� yrt/vtf3��E�Fl� CO. MAILING OR S'TR/E�ETPODRESP p / bosbidkan O INDIVIDUAL 0 LOCAL-AGENCYSTATEAGENCV �� /. /7vv� CORPORATION (] PARTNERSHIP D COUNTYAGENCV = FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE L 22z;` 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: I.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CbRRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY ' COUNTVu JURISD�ICTIONg FACILITY 7f LOCATION CODE -OPTIONAL CEZSTRACT*-OPTIONAL SUPISOR;DISTRICT CODE -OPTIONAL 9.2 THIS FORM MUST BE ACCOMPANIED BY AFT LEAST(1) (1)OR MORE PERMIT APPLICATION-L1FOOI RM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(9-90) FOR0007A412