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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD m� ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY T NEW PERMR 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT Q A AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACILITY NAME NAME OF OPERATOR - G/./7 me flick-er ADDRESS NEAREST CROSS STREET PARCEL/(OPTIONAL) RA CIN NAME STATE ZIP CODE SITE PHONE WITH AREA CODE Le CA 5 q0 -970e 2a?-333 - 06 TO Box CORPORATION a INDIVIDUAL I=PARTNERSHIP Q AGENCY O COUNTY AGENCY O STATE-AGENCY I] FEDERAL#GENCY DISTRCTS TYPE OF BUSINESS � � GAS STATION Q 2 DISTRIBUTOR O pEe IF INDIIAAN a OF TANKS AT SITE E.P.A. L D.a(q danaQ 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIR" PHONE a WITH AREA CODE M., w 1 —3 -9" NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION as 1 MAILING OR STREET ADDRESS / Eoabk19a O INDIVIDUAL a LOCAL-AGENCY IEj STATE-AGENCY ED CORPORATION 0 PARTNERSHIP O COIINTYAGENCY E:j FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION GS MAILING OR STREET ADDRESS EN bh101f2M Q INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY Cl CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDEML#GENCY CITY NAME STATE ZIP CODE PHONE#WITH ATEA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -FF I-I I I I 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.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(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ® = as LDCATIONCOOE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTE -OPTIONAL 2-7Z-- COD1^ 31,� 9 f^ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. V` FOR9W]A-R2 FO A(9-90) n^