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SDUaCnS ec „ co STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA nil, C COMPLETE THIS FORM FOR EACH FACILITYISRE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME. NAME OF OPERATOR Ulm�fv f.1 ADDRESS NE EST CROSS STREET PARCEL#(OPTIONAL) j35A I r-. MOCI OSE-1 0171c caN CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE mos khr-1 CA z --yss -- • 3.zo I/ BOX COUNTY AGENCY STATE-AGENCY FEDERAL-AGENCY TO INDICATE CORPORATION INDIVIDUAL DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ✓ kF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optonaq ❑ � RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OA TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS:j^AME(LAST.FIRST) PHONE#WITH AREA CODE LP-;'. _E 657 _ 2-0 f� f'S4. C. NiGNTS• AME[LAST,FIRST) PH NE#WITH AREA CODE NIGHTS: .AME(LAST,FIRST) PHONE WITH AREA CODE �y Ave-54 ALL II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED r CARE OF ADDRESS INFORMATION NAME e C 4 J(�1 MAILING OR STREET ADDRESS Vb0x Oo'ndicala 0 INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY ff�� p Q CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY CITY NAM V 57AE��jT PHONE#WITH AREA CODE 'l� � Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) OARS OF ADDRESS INFORMATION NAME OF OWNER AdA1LINO0RSTREETAODRESS J Wb box [] INDIVIDUAL = LOCAL-AGENCY © STATE-AGENCY Q CORPORATION [] PARTNERSHIP =COUNTY-AGENCY [] FEDERAL-AGENCY CITY NAME �TE �Z$pDE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 - V, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank oW r unles b I or fl is checked. CHf OK 4NE SOX LNDIGATING WHIGH 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 BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT S NAME[PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTPJDAYIYEAA LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT OPTIONAL 22 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONRoYY, R FORM A(5-90)