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OU9 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W ... UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A .0 ry'i COMPLETE THIS FORM FOR EAC CtL1TYlSITE MARK ONLY Q T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERM AN LY CLOSED SITE ONE REM [-] 2 INTERIM PERMIT 0 d AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY NAME / NAME OF OPERATOR ADDRESS _ NEAREST CROSS STREET PARCEL#(OPIONALI /rA^L9 CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE S G� /9h CA TO I/ Box O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUKrY-AGENCY 0 STATE-AGENCY 0 FEDERAL#GENCY 'mRCTs TYPE OF BUSINESS 0 I GAS STATION 0 2 DISTRIBUTOR gE/ IF INDDIAN #OF TANKS AT SITE E.P.A L D.a(aww") Q 3 FARM Q 6 PROCESSOR a 15 OTHER On TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME ILAST,FIRST) ! HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE i e . ; k 76 7/ NIGHTS: N ME(LAST,FIRST) ! PHONE# H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS `! wolmE O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 6 19 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME ISTATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS bnmtl 0INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY _ 0 CORPORATION 0 PARTNERSHP 0 COUNTY-AG WY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD 0 OUALIZATION UST STORAGE FEE CCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) H 4 4 - v 3 J 1 V. LEGAL OTIFICATION AND BILLING ADDR Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE SOX1111<ATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.a III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLK)ANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# - /V!(J/U L/-j Ell FTTI / / LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL r) ra3si) 3 . 7Ilyv c.J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. F011�FORMA(490) f