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STATE OF CALIFORNIA 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A , o; ry, °�gnon+`n COMPLETE THIS FORM FOR EACH F CILITYISITE MARK ONLY ❑ NEW PERMIT ❑ S RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 3 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME /� NAME OF OPERATOR F0� PARCEL 9(OPTIONAL) ADDRESS NEAREST CROSS STREET STATE ZIP CODE SITE PHONE s WITH AREA CODE CITY NAME GCA 22 TOIN Box 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY0 STATE-AGENCY 0 FEDERALAGENCY DISTRICTS S ❑ 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A L D.#(optimal) TYPE OF BUSINES ❑ RESERVATION O O 3 FARM O d PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY WNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional GAYS::�NAME(LAST•FIRST) //' PHONE#WITHAREACODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE /�//w '33 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS �� ✓ boatlinAkale INDIVIDUAL OLOCAL-AGENCY (] STATE-AGENCY Pn !� Q CORPORATION = PARTNERSHIP 0 COUNTYAGENCY FEDERAL-AGENCY (! STATE ZIP CODE PHONE#WITH AREA CODE2 CITY NAME III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM FOWNEERR CARE OF ADDRESS INFORMATION NAM ✓% / MAILING OR STREET ADDRESS ✓ boabmtl¢al# IIwD NOUAI O LOCAL AGENCY QSTATE-AGENCY CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE AREA CODE GGEis / ��' �i 22• 2C #WIiH1 — 33 IV. BOARD OF EQUALIZATION �UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 5—T-CL L�� V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE 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 BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PR INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FAICIILL.IT��Y�# _ ® �---"� LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVLSOR-DISTRICT CODE -OPTIONAL Z?7- G THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORDWDA-R2 FORM A(9-90)