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- w e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD " o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYSRE ""'O""�• MARK ONLY Q T NEW PERMIT Q O RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 RMANE?MLX_ ggED SRF�JT„ ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OBA OR FACILITY N E / NAME OF OPERATOR ADDRESS 33 -7 �� fJEARE$T CROSS I PMCELt CITY NAME STATE(/,•_C_7/ZIP CODE SITE PHONE 0 WrIH AREA CODE 00 BOX CA 953 s� TONDCATE ORATION Q SmNOGAL Q PARTNERSHIP p LOMAGENCY Q COUNTYAGENCY Q STATE-AGBRCY p FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTORa RESERVA✓ IF INTION DIAN A OF TANKS AT SITE E.P.A L 0.s&VOwmO O 3 FARM a 4 PROCESSOR 5 OTHER OR TRUST LANDS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE$WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE$WITH AREA CODE NIGHTS: NAME(LAST, RST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE$NATN AREA CODE r IL PROPE ER INFORMATION MUST BE COMPLETED 1 NAME CARE OF ADDRESS INFO ` AILING OR STREET ADDRESS w, &oa oirooN Q WDIVDU4 p LOCAWSENCY Q STATE-AGENCY 2 S7 Q CORPORATKN Q PurrN�SwP Q COUNTYAGENCY Q FWMALAGENCY CITY NAME I STATE I ZIP CODE YGd PHONE s WITH AREA CODE C7 5 S III. K OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OCARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ lx.bmsA Q IMXVIDUAL Q LOCLAGBICY p STATE-AGENCY Q COIRRTRATWM p PARTNERSHIP p COUNTYAGENCY Q FEDERAL.IGEWY CITY NAME STATE I 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 F4-F4-1- V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.U 11.17 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICAN75 TIRE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY a Li_L/i�li 6 LOCATK)N WOE -OP77 ONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL - 05 3 z6- -- THIS FORM MUST BE ACCOMPANIED BY AT LEAST 0)OR MORE PERMIT APPLICATION- FORM S, UNLESS THIS IS A CHANGE OF SITE WFORMATION ONLY. �RFGIORUAA2 FORM A(9-901