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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACIUTYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHgNGE OF INFORMATION ONE ITEM ❑ 2 INTERIM ❑ 7 PERMANENTLY CLOSED SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME G /"�!`#'f..•' ` u ® O� NAME OF OPERATOR ADDRESS '� '� O / �J� [.wgviy/� NEAREST CROSS STREET PARCELN(OPrgNAq CITY AME O zoo _ O STATE Z� D� S�pHrE#WITH AREA CODE ✓ BOX CA M1 TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY DISTRICTS D COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A, L D,#(op(lmal) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER RESERVATION 7 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#WITHAREA CODE NIGH7S: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME �C f/ Cap" /`W-41/ C CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS GTNKfr (/ /I IL. ✓ box blMkam 0 INDIVIDUAL 0 LOCAL-AGENCY ��7 0 PARTNERSHIP ED FEDERSTATEAL-AGENCY GENCY CITY NAME D CORPORATION 0 COUNTY-AGENCY 0 FEDERALAGENCY �G /✓_ STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) nNAMEOFOWNER ` �G �v� CARE OF ADDRESSIS /�68 7 box binOkam LOCAL AGENCY O STATE-AGENCY 51-4� O CORPORATION 0 PARTNERSHIP 0 COUNTY.AGENCY 0 FEDERAL-AGENCY STATE ZIP CODE (J� PHONE#WITH AREA COUE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916) 1J9-Zb82 if questions arise. TY(TK) HQ4 4 -� 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: I.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT APPLICANT`S NAME(PRINTED a SIGNATURE) APPLICANTS TITLEDATE MONTWOAYNEAp LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FA LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL GJ 3UPVISOR-DISTRICT CODE -OPTIONAL 6 23• _'t ' 3 z6 9L THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS FORM A(9-90) THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR / OW9Ap2