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• STATE OF CALIFORNIAL STATE WATER RESOURCES CONTROL BOARD su o UN RGROUND STORAGE TANK PERMIT APPLICATION • FORM A COMPLETE THIS FORM FOR EACH FACIMISITEF MARK ONLY T NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT Q d AMENDED PERMIT 8 TEMPORARY SITE CLOSURE — I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME / AME OF OPERATOR 4 _ i j-FS r ! D tW a,n f S 5 lkn .SP,✓•ct CTP 1-A-. ADDRESS I NEAREST CROSS STREET PARCEL#(OPTIONAL) 3s 357r', !� /e. CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE 5"'w/ CA y sd u! dv7 -9, 1/ -orl BOA TO INDICATE OHL216PORATION Q INDIVIDUAL Q PARTNERSHIP =LOCAL AGENCY Q CAUNTYAGENCY =STATE-AGENCY Q FEDERALAGENCY DISTRICTS TYPE OF BUSINESS F7 1 GAS STATION O 2 DISTRIBUTOR - RESERVADTION #OF TANKS AT SITE E.P.A. I.O.A(apIlmA) Q 3 FARM Q d PROCESSOR d5 OTHER OR TRUST LANDS 1- EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE l/ -2 NIGHTS: NAME T,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING 6RSTREET ADDRESS ✓ boxb W"m Q INDIVIDUAL Q LOCAL-AGENCYQ STATE-AGENCY -O l&OX 3/10 =CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 5Aplc 4-11 C/4 r?,A 9s -9V.3 -os III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS but it dkw = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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) HQ 4 4 - 0 ,9 1 L/IS 13. V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] II.O 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY = COUNTY u JURISDICTION x FACILITY# # P/TT 5 3 S- aN °r -- LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3 Co/S ! THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, FOR FORM A(e-90) rA� _ OW9AA7