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-�cou- ea STATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD p UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A -•C-tTO-M�e COMPLETE THIS FORM FOR EACH F ILTTYISITE MARK ONLY Q 1 NEW PERMIT 0 3 RENEWAL PERMIT 8 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE ITEM Q 2 INTERIM PERMIT p 4 AMENDED PERMIT I] 8 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION& ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR V I i-k 4Af•0—r 4RD#1AtT-7E ADDflESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) CITY NAME STATE ZIP CODE ITE PHONES W�rH REAE 5�� CA 4 ZO Zoa) `1b —43 T 1NOICA 0TE p CORPORATION p INDIVIDUAL 21'PARTNERSHIP p I.00AL.AGENCY p COUNTYAG r p STATE-AGENCY p FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O 1 GASSTATIONp 2 DISTRIBUTOR p ✓ IF INDIAN A OF TANKS AT SITE E.P.A L D.i(go8m9Q RESERVATION p 3 FARM p / PROCESSOR 5 OTHER OR TRUST LANDS O EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE IL PROPERTY OWNER INFORMATION- UST BE COMPLETED NAME _ j -5D �� CARE OF ADDRESS INFORMATION tJ MAILING OR STREET ADORE58 ✓ �blndbaN p INDIVIDUAL p LOCAL-AGENCY p STATFAGENCY D OBG p COXPoRATION PARTNERSHIP p COUNTYAGENCY p FEDERALdGfNCY CITY yAME STATE ZIP COD PHONE s WITH AREA CODE j>!g �J D III. TANK OWNER INFORMATION- UST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION �idwL rJSo RFE L MAILI OR STREET ADDRESS II bintlbW p INDIVIDUAL Q LOCALAGENCY p FATE EAGENCY CORPORATION p PARTNERSHIP p COUNTY.AGENCY p FEDFRAL#GENCY CITY NAME STATE ZIPCODE PHONE i WITH AREA CODE gy70 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQF4 F4 -� V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[::] 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY• JURISDICTION R FACILITY R LOCATION CODE -OPTIONAL CENSUS TRACTS .OPTIONAL SUPVNiOR-DISTR TCOOE -OPiIONAI O 1 23. So ;; z��Ri X-7— THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(9-90) FORW1JMi2