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• • c60UR STATE OFCALIFORNIA CON n STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e • ORI,ROR�,� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUR 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D A R®CILITV NAA NAME OF OPERATOR ADD 51 &6 '[ INo0�' E N $E TCROSS STREET PARCEL#(OPTIONAL) CITY NAV STATE Z140DE SITE PHONE$WITH AREA CODE CA ff11 ✓ BOX CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY I�COUNTY-AGENCY (] STATE-AGENCY FEDERAL-AGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.x(apHma# RESERVATION 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE$WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE c�7 - OO . N IV-2300 NIGH TS: NAME(LAST.RUT) G PHONE�IAREA CDC . NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE ,Nllr�y./�e.11 V II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED N& CARE OF ADDRESS INFORMATION Ce*FW MAILING OR STREET ADDRESS ✓ boll bind"Is D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY DRPORATION E-1PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY CI FAME STATE ZIP CODE PHONE#WITH AREA CODE LK6eN1 1 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADORES ✓ box bintllcau INDIVIDUAL OLOCAL-AGENCY 0STATE-AGENCY I�CORPORATION Q PARTNERSHIP I=COUNTY-AGENCY Q FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE$WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ F41_4]- O O d 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 PE TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTEDx SIGNATU APPLICANTS TITLE DATE MONTWDAV/YEAR w. wM62 Am IN �TC�I (b- LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ® I I I / I I I 8 I/ U woAT�13 LOCATION CODE -OP77ONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 23-190 3z3 2/%/9xf THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. Rz FORM A(9-90)