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cgOUN � STATE OF CALIFORNIA i STATE WATER RESOURCES CONTROL BOARD ey UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITWSRE MARK ONLY Q ) NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION p 7RMANENbYlATSED S l ONE ITEM 2 INTERIM PERMIT ' a AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACILITY NA E NAME OF OPERATOR I/ q;M od5 X1 ADDRESS �fE)f/✓ �� NEARESTCROSSVFET / PARCEL*( OPTIDNAU CITY NAME STATE ZIP CODE SITE PHONE i WITH AREA CODE l o CA 953Nsc TOIN BOX Q'LORPORATN)N I=INDIVWAL p PARTNERSHIP p LOCAL-AGENCY p OOUNTY-AGENCY p STATE-AGENCY p FEDEPAL-AGENCY pSTRIM S TYPE OF BUSINESS Q ) GAS STATION Q 2 DISTRIBUTOR p R✓SEA ATIO i OF TANKS AT SITE E.P.A L D.i(ryYV W) p 3 FARM Q 6 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE*WITH A(RREEA CODE DAYS: NAME(LAST.FIRST) PHONE*WITH AREA CODE O k'r - �_ .5" - 21 � 2 5(J NIGHTS: NAME(LAST, T) PHONE*WITH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONE*WITH AREA CODE 11. PROPE ER INFORMATION MUST BE COMPLETED NAME 1 CARE OF ADDRESS INFORMA'11N 1 / AILING OR STPEET ADDRESS ` / '� Ooib W[aH p I p LOCK-AGENCY p STATEAGBICY 2 L1 p CORPORATION p vMT SMP p COUNNAGENCY p FEDEML-AGENCr CITY NAME ( STATEZIP CSE 5 PHONE i WITH AREA CODE \ d Y1 Ill.--K OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OW CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS EwbFOYAY p monom CD LOCAL-AGENCY p STATEAGENCY p CORPORATION p PARTNERSHIP p COUNTYAGENCY p I MERALAGENCY 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 IL is checked. FCHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.p II.p OIL O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY a �f/vL AI u by I f LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICTCOOE -OPPONAL - Y - 05 3 z 4, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.A42 FORM A(490) //y/