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• STATE OF CALIFORNIA :' c�i STATE WATER RESOURCES CONTROL BOARD 3 mom' o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 3 r , COMPLETE THIS FORM FOR EACH FACILRYISRE MARK ONLY E] d NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAMEOiSS e000b7 NAME OF OPERATOR l # ADDRESS, 1 NEAREST CROSS STREET PARCEL#OPHONAU // -F. W CITY NAME STATE ZIP CODE SITE PHONE'WI AREA CODE CA TO INDICATE TE a CORPORATION INDIVIDUAL F-7O PARTNERSHIP LALL-AGSENCY 0 COUNTY-AGENCY 0 STATEAGENCY 0 FEDERAL-AGENCY TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aplbl) w RESERVATION O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIM RY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(( ST.FIRST) PHONE#WI AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH EACODE NIGHTS: NAME(LAST.FIRST) PHONE*WITH AREA CODE II, PROPERTY OWNER INFORMATION- MUST BE CO LETED /� CARE FADDRESSINFORMA ION �M NAMUl" C4 p-viV•r �I1 • - MAILING OR STREET ADDRESS I S N '61 Vd x ibox 0l taO INDIVIDUAL I O LOCAL-AGENCY STATE-AGENCY CORPORATION = PARTNERSHIP COUNTY-AGENCY FEMRALAEN CY CITY NAME ST]jE w ZIP CODE P ONE#WITH A EA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CAPE OF ADDRESS INFORMATION MAILINGOR STREET ADDRESS ✓ box 0Indicate = INDIVIDUAL O LOCAL-AGENCY STATE AGENCY ED CORPORATION = PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME TATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMB Call(916)739-2582 if questions arise. TY(TK) HQ [-4p4 - b V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification an 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: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TIRE I DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY #Y R LOCATION CODE -OP7iONALA--L��----"'' CENSUSTRACT 0 -OPTION 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 ONbLY37A R2 FORM A(9-90) �� ] —/ ') r T`• N&G) ,d i��i o f Q � 4.2J. /'�� l / '7� v