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a STATEOFCAUFORMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AFACILITY/SITE V COMPLETE THIS FORM FOR EACFACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT KS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM F-12 INTERIM PERMIT El AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE `3 I. FACILITY/SITE INFORMATION A ADDRESS. 1MIIST WF rntual FTFni DSAORF ILITYNAME PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) NAME OF OPERATOR NIGHTS: NAME (LAST, FIRST) ADDRESS NIGHTS: NAME (LAST, FIRST) - PHONE S WITH AREA CODE LOCATION CODE - OPTIONAL N REST CRO STREET SUPVISOR- DISTRICT CODE - OPTIONAL PMCEL#(OP/ONAy CITU NAME STATE ZIP CODE I SITE PHONE # WITH AREA CODE LfxCd� CA BOX T NDCATE CORPORATION D INDIVIDUAL D PARTNERSHIP 0 LOCAL -AGENCY D COUNTY -AGENCY (] STATE -AGENCY Q FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN l# OF TANKS AT SITE E. P. A. L D. # (Wknao ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PFRRnN 1SFnnNnAQV1.. fl—I 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 S WITH AREA CODE IL PROPERTY OWNER INFORMATION - (MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box fad 0 INDIVIDUAL O LOCAL -AGENCY D STATE -AGENCY O CORPORATION 0 PARTNERSHIP O COUNTY AGENCY 0 FEDERAL -AGENCY CITY NAME - 9TATE ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bMNkab INDIVIDUAL LOCAL -AGENCY STATE -AGENCY D CORPORATION O PARTNERSHIP E�j COUNTY -AGENCY O 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) HO 4 4 -L__Ll_ I I I I 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. ❑ IL ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME (PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION # FACILITY # S / LOCATION CODE - OPTIONAL CENSUS TRACT- OPTIONAL SUPVISOR- DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORUR}TA.M \ FORM A (990) ii