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STATE WATI STATEOFCAUFORWA ora es R RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A 0 �o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ � NEW PERMIT ONE ITEM ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ T PEgMANENTLY CLOSED SITE ❑ e TEMPORARY 317E CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BECOMPLETED) DSAORFACILITVNA E ADDRESSC C L^ NAMEOFOPERATOR CITY NAME I//1y M N 's NEAREST CROSS STREET PARCELN(OPrx)NAL) STATE ZIP CODE I r 2-,()_lO Z v BoxG.A SI PH E#WITH AREA CODE TO NDIC TE E:1 CORPORATION 0 INDIVIDUAL oI PARTNERSHIP E:1 LOCAL-AGENcy SQ TYPE OF BUSINESB 1 GAS STATION DISTRICTS 0 COUNTY-AGENCY0 STATE-AGENCY 0 FEDERAL-AGENCY ❑ Q 2 DISTRIBUTOR Q 3 FARM O 4 PROCESSOR 5 OTHER O RESERVATDIION i OF TANKS AT SITE E.P.A. L D.#(CPo r yj OR TRUST LAN DS EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)- PHONE#WITH AREA CODE I optional DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM 11 y N.'Y0 UU�'r ,rw T CA OF ADDRESS INFORMATION MAILING OR STREET ADR--- w 1 �C46 m,A-1 V CITY AME W G O CORPORATION 0 INDIVIDUAL Q LOCA-AGENCY STATE AGENCY S ST pJE 1�PARTNERSHIP 0 CpUN y#GENCV 0 FEDERAL GENCY /l(Apt ZIP CODE 9 PPOLryE y,INITH AREA CODE WMI\l III. TANK OWNER INFORMATION-2 UST BE COMPLETED) NAME FOWNER fVCARE CFACPRESS INFORMATION MAILING ORSTREETADDRESS YA7-�1 ✓boa b4gkale � YVIT LIV CITU NAME &ua O CONPoganON INDIVIDUAL (] LOCAL-AGENCY O STATE.AGENCV ARTNERSWP (]COUNFY,IGENCY STATE ZIP CODE AC FEDERAL `�� PHONEi WITH AREA CO IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)7739-2582 if questions arise. 3— lob TY(TK) HO 4 4 -� 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.®' III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# ICTION# ® FACILITY LOCATION CODE - 77ONAL CENSUS TRACT#]-0P]T0M4]L ] L 7\ 3UPVISOq-DISTgICT CpOE - F © OPTIml ONAL THIS FORM MUS BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. V A(aPO) C1`0110073AA2\