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n f9 STATE OFCAUPoRMA • �.f�5 `Oti STATE WATER RESOURCES CONTROL BOARD i a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A V .a / COMPLETE THIS FORM FOR EAC ACILfTY/SRE I MARK ONLY F7 I NEW PERMIT 0 G RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR el I ADDRESS NEAREST CROSS STREET PARCEL#(OFMONAL) 15 CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA BOX TOINOICATE O CORPORATION O INDIVIDUAL a PARTNERSHIP O LOCAL-AGENCY Q COUNTYAGENCY STATE-AGENCY FEDERAL-AGENCY DLSTWCTS TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTORQ RESERVATION✓ IF INDIAN #OF T S AT SITE E.P.A. I,D.a Ioplka ) O 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,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓pox IDWicate D INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY C3 CORPORATION PARTNERSHIP Q COUNTY AGENCY Q 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 MAILING OR STREET ADDRESS WX xomicau � INDIVIDUAL _ Q LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP = COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE LP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -EIT= 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 SE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.F7 III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYf/EAfl LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# ® FT-7 LOCATION CODE -OPTIONAL CENSUS TgACT# -OPT © SUPVISO (STRICT CODE -OPTIONAL Z3. v� I THIS FORM MUST BE ACCOMPANIED BY ATL T(7)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(390) FOR0000A-R2