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6oYn e — STATE OF CALIFORNIA "— gn +� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� yj ~F l.. o' anY Y COMPLETE THIS FORM FOR EACH FACILITYISRE MARK ONLY T NEW PERMIT F-1 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY N NAME OF OPERATOR (/[ 2 oS ADDRESS NEAREST CROSS STREET PARCEL#(OPRONAL) C7 C Lo t/ CITY NAME STATE ZIP CODE S51i PHONE WITH AREA DE Ifo CA 53�f7 q z37, y7.V� v BOX TO INDICATE rJ""^^'^A I�INDIVIDUAL O PARTNERSMP O LOCAL-AGENCY l�CWNTY#GENCY l�STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS E;rl GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E,P.A. L D.a(aPHvW) RESERVATION Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONE t WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION fC t MAILING OR STREET ADDRESS ✓bwbbdbab = INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY Lis Qf 7V yh 7 l�CORPORATION = PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE 1\� oeniX III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Wx b Wicam INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY 0 CORPORATION PARTNERSHIP COUNTYAWKY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -10101 (j 101 V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II, III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR INTEO b SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY CIOOUYIa TINTGJURISDICTION# FACILITY# CIF-CL �6 �T LOCATION CODE -OP NAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR00]3AF2 FORM A(9-90) - 4�