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STATE OF CALIFORNIA �. STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 0 COMPLETE THIS FORM FOR EACH FACT BRE MARK ONLY Q I NEW PERMIT F7 3 RENEWAL PERMIT n-5—CHANGE OF INFORMATION O 7 PERM OSED SITE ONE REM O 2 INTERIM PERMIT = 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE - I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITVNAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL i(0 _ CRY NAME STATE ZIP CODE �/- SITE PHONE i WITH AREA CODE I/ BOX CA TOINDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY M COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS I GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.i(gofimalJ RESERVATION Q D FARM O d PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA COOE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ W;c biMi Q INDIVIDUAL = LOCAL AGENCY Q STATE AGENCY O CORPORATION Q PARTNERSHIP = COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS mFbmOicLx Q INDIVIDUAL Q LOCAL AGENCY STATE-AGENCY (]CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ F4-1-4] C Id I / S 6 S �V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLWG: I. H.O III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PRIN TED A S IGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY T COUNTY C JURISDICTION A FACILITY K STOck LOCATION CODE -OPTNNML CENSUS TRACTi -CP�RAL SUPVISOR-DISTRICT CODE -OPTIONAL i THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(9-90) FORIXTIA.I"