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RC[y STATE OF CALIFORNIA '�• STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "• �e COMPLETE THIS FORM FOR EACH FACILITYISITE °"•AOR"••- MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM O 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAp5 ITYN ^ '•Y��•� NAME OF OPERATOR ADD{{JJ--ESS /r�IW NEAREST CROSS STREET PARCELS(OPTIONAL) l 13C�ern'1 CITY NAME e o STATE ZIP CODE SITE PHONE#WITH AREA CODE AW/� CA BOX TO INDICTE E-1 CORPORATION Q INDIVIDUAL Q PARTNERSRIP Q LOCAL AGENCY Q COUNTYAGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ ) GAS STATION Q 2 DISTRIBUTOR O ✓RESERVATION INVATION DIAN #OF TANKS AT SITE E.P.A. I.D.#(opllan#lj O 3 FARM O A PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH 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 ✓Dox bNMbm Q INOIVIOUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING ORSTREETADDRESS box badiWa Q INDIVIDUAL IQ LOCAL-AGENCY IQ STATE-AGENCY IQ CORPORATION Q PARTNERS14P Q COUNTY-AGENCY IQ 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 4 4 -� 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 IL❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# $:131 LUDI ri(o I / F51 f al LOCATION COPE -OPTIONAL CENSUS TRA�� THIS FORM OPTIONAL SUPVISOfL-DISTRICT CODE -OPTIONAL ]MUST BE ACCOMPANIED BBYY AAT LEAST(1)OR MORE PERMIT APPLICATION• F`0{JRMM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOROD7A-Rt FORMA(490)