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�co�n e STATE OF CALIFORNIA • `: STATE WATER RESOURCES CONTROL BOARD 3y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �� "°' �o 400eM� COMPLETE THIS FORM FOR EACH FACI E MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ;?--S'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED RITP ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAORF CILITYNAME NAMEOFqry�l6 RATOR me �v „G I $ lic a S ADD SO �. NEEEST CR SS TREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE ITE PHONE#WITH AREA CODE o ca 5 3Lis zo 19-2 53 ✓ BOX TOINDICATE OflPORATION D INDIVIDUAL PARTNERSHIP (]LOCAL-AGENCY D COUNTYAGENCY =STATE-AGENCY O FEDERALAGENCY DISTFUCTS TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR = -1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR QjBTFiETi OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE «s �ana 2© 5 _ z3 NIGHTS: NAME(LAST,FIRST) 1 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME ^� yl( CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESSc ✓ box blnd� O INDIVIDUAL LOCAL AGENCY STATEAGENCV 'Z3 2�e- 7 CORPORATION = PARTNERSHIP =1 COUNTY-AGENCY FEDER4LAGENCY CITY NAME \ ©� (STA�i� ZIP CODE P ONE#WITH AR ODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) S 2 NAMEOF WNER CARE OF ADDRESS INFORMATION 1 (t MAILING OR STREET ADD ESS ✓ box 0lndUW 0 INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP =COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE sc�L. IV. BOARD OF EQUALIZA,T�,, I.O,�N LIST �STOR�AGGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 - 10 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.Ff� 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# We0'v �J /T IY 7I/ LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL 23 3IZ6 -- L7- Z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SR INFORMATION ONLY. FORMA(9-90) 3A R2