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eyouA.es STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD `.` o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A C11-1 COMPLETE THIS FORM FOR EACH FACT YISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OF;FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) —777 S . Gem C_ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA 953 3L ✓ BOR ORPORATION INDIVIDUAL [] PARTNERSHIP 0 LOCAL-AGENCY ] COUNTY-AGENCY OSTATE-AGENCY �] FEDERAL-AGENCY TO 1 N DICATE DISTRICTS TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE y DAYS:: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAM ( AST,FIRST) PHON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODs= S�kv� C' II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ` CARE OF ADDRESS INFORMATION W�L71✓ei'-' Imo/!C#�t _ _ MAILING OR STREET ADD RES9 box igiridicate [7 INDIVIDUAL 0 LOCAL-AGENCY STATE•AGENCY !—G C/ORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION SCS i�� It C7,,C MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY ©CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CIN 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 - V. LEGAL NOTIFICATION AND BILLING ADDRESS Legai notification and billing will be sent to the tank owner unless box I I is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETE©UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHVDAYNEAR LOCAL AGENCY USE ONLY COUNT Y# JURISDICTION# FACILITY# U 111 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR0033A-R2 FORM A(9-90)