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• Scoon e <br /> STATE OF � ''o <br /> STATE WATER RESOURCES CONTROL BOARD ;�> �a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A . `� y; <br /> P JT). O <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �""°""��. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT EV�L 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE L�3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) `J <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> We <br /> CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> n cA <br /> I/ BOX <br /> TO INDICATE O CORPORATION [71 INDIVIDUAL PARTNERSHIP (]LOCAL-AGENCY 0 COUNTY-AGENCY <br /> DISTRICTS 3TATE'AGENCV 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR O '/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(op(ionap <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bMdkaw O INDIVIDUAL LOCAL ENCY E] STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP (] COUNrY.AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION• (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS v box lolMkai# INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> __. =CORPORATION Q PARTNERSHIP L-1COUNTYAGENCY (] FEDERAL-AGENCYCITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY JK) HQ4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 It.D III O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JHR+SBIC�IbIV'A$W.Qp,Ps FACILITY# <br /> o0o S mjC) t2 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL lb�� <br /> C/ a3, 8D 3a 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(490) FOR0073A-R2 <br />