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STATEOFCALIFORMA • W�..«a� '��O„ STATE WATER RESOURCES CONTROL BOARD ��,m' v a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y e . . o �Y . COMPLETE THIS FORM FOR EA H FACILITYISITE �.��.a�� MARK ONLY Q t NEW PERMIT F-1 3 RENEWAL PERMIT M 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 5 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY NAME - NAMEOFOPERATOR Les Cal .its LPs (oakYNs ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 9s�1 N- r h CITY NAME �+ STATE ZIP CODE ZO SITE PHONE WITH AREA CODE CA I/ BOX TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY OCAL-�S CY 0 CWNrY-AGENCY � STATE-AGENCY 0 FEDERAL-AGENCY DISTRITYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN It OF TANKS AT SITE E.P.A. L D.a(apNma/) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 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,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE I!. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bm bindlcat# 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bobimInAS 0 INDIVIDUAL 0 LOCAL-ACERCY O STATE-AGENCY 0 CORPORATION O PARTNERSHIP 0 DOUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ [4__F4 -1 1 1 1 1 1 ] 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.a 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# �] © C,46kz /9 LOCATION CODE -OPTIONALCENTRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL SUS 99 3, ,b xmsAf c THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR IM R2 FORM A(9.90)