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• '160UR ; C STATE OF CALIFORNIA 9 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 04,/OR W" COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBAOR FACILITYNAME NAME OF OPERATOO - /) /5 lL N n(s // 1"fl7 rer/w! tC�i4-„p /71 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) y o� AL a CITY NAME STATE Z CODE 31TEPHONE#WITH AREA CODE fp,N CA ZO¢ '16-L16ggl BOX CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY L-AGENCY COUNTY-AGENCY STATE AGENCY 0 FEOERALAGENCY T DISTRICTS TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ❑ R/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apfional) O 3 FARM O 4 PROCESSOR V 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) - PHONE#WITH AREA CODE els1, t c d oe S' e � Xo - /-i4o3 NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME( .FIRST) PHONE#WITH AREA CODE H. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED NAME - CARE OF ADDRESS INFORMATION J MAILING OR STREET ADDRESS ✓ Lor blMkale E--I INDIVIDUAL O LOCAL-AGENCY =1 STATE-AGENCY // 0 Z> ED CORPORATION lLj PARTNERSHIP L�j COUHTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH.AREA CODE Lool; 3� D ?o - -,1 R7 III INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CkT N� L ,�/ Or CARE OFC DRESS INF,fJRMATIO�N,oft -Q0 MAILING OR STREET ADDRESS r ✓ box bl scale INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 00 CORPORATION PARTNERSHIP D COUNTY-AGENCY L-1FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHONE#WITH AREA CODE G4 95zo� IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -p 3 2 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.O II.❑ U. 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 MONTWOAYN AR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3� I I 1 / 16 1161 5-r0CK'/Y CE LOCATION CODE -OPTIONAL NSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 91 .7 s, go y.to z 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. FOR0033A R2 FORMA(9-e0)