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141.10, STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A v a • . a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT6 CHANGE OF INFORMATION ONE ITEM O 2 INTERIM PERMIT a T PERMANENT OSED SITE4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE F 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J DBA OR FACILITY NAME c NAME OF OPERATOR u ADDRESS NEAREST CROSSSTREET PARCEL#(OPrIONAU CITY NAME /N r P S / Vk / --t STATE ZIP CODE SITE PHONE i WITH AREA CO DE I/ BOX LTJ 'r0 CA 95 �-u� �u9-yes-ss� TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q —..UT Q COUNTY-AGENCY DISTRICTS IQ STATE-AGENCY Q FEDERLL#GENCY TYPE OF BUSINESS O GAS STATION 0 2 DISTRIBUTOR 1 77 0 ✓ IF INDIAN i )F TANKS AT SITE E.P.A. I.D.i(Fpioniq 03 FARM = 4 PROCESSOR OTHER ORATION TRUSRVANOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonel DAYS: NA�EjLA$T,FIRST) PViONE+/WITH AREA CODE DAYS: NAME(LAST,FIRST) CO/Y 7- �G� ��—t'`�-�S� PHONEi WITHAREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME 10G k- 00/1CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boxb Wicale = INDIVIDUAL S7 Or ()U Q LOLL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY#GENCY Q FEDERAL#GENCV CITU NAME STATE ZIP CODE � WI A3 PHONEt THAREACODE III. TANK OWNER INFORMATION• MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS box 0hQ INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY __ Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY CITU NAME STATE ZIP CODE PHONE i WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -p y 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. 11.O III,Q THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# d/»a ] 31 I I I a G 1-71 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. FORMA(9-80) If// � _i e� 1