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STATE OF CALIFORNIA 14.1100' �e�� i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :mom as COMPLETE THIS FORM FOR EACH FACILTTYISITE MARK ONLY Q T NEW PERMIT O S RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM F-1 2 INTERIM PERMIT Q d AMENDED PERMIT O a TEMPORARY SITE CLOSURE S3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR ADDRESS p p / NEAREST CROSS STREET PARCELO(OPrONAU 7 /" CITY NAME //-- STATE ZIPCODE SITE PHONE WITH AREA CODE h Alec-,,. CA TO INDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHP Q LOCALAGENCY COUNrY-AGENCY Q STATE AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS a T GAS STATION Q 2 DISTRIBUTOR a ✓ IF INDIAN 19 OF TANKS AT SITE E.P.A. L D.#(optimal) Q 3 FARM a A PROCESSOfl Q 5 OTHER OR RESERVATION TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE N5: E(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE S 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ^ , CAREOFADDRESS INFORMATION MAILINGSTREET ADDRESS ✓ b" M 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY ro Q O CORPORATION ED PARTNEFJSNW O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE 6s- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS b"bWimi* INDIVIDUAL C:l LOCAL AGENCY O STATE-AGENCY a CORPORATION PARTNERSHP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. TY(TK) HQ 4 4 -FI—T—FT—T--] V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box J or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL Q III. 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 TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNT# JURISDICTION# FACILITY# 1010 1 / IV d Z LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL A 3J-D I 3� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(9-90) FOROROAA2 t�) S—a8�i — 1.d, t5I iA