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STATEOFCAUFORNIA • - 'croup ,��` STATE WATER RESOURCES CONTROL BOARD t'o� y-o' UN RGROUND STORAGE TANK PERMIT APPLICATION - FORM A q r f o ry: . COMPLETE THIS FORM FOR EACH FAC1LITYISITE EMARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ & AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE , I. FACILrrY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OBA OR FACILITY NAME � _ r_ I-t7AME OF OPERATOR � �ur If rnJ�n e C�'1' e-W S�ko .SPi✓.ct Cw- ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAU 35- 3 r, h'+ ,. /-/t_ CITY NAME STATE ZIP CODE SITE PHONE+WITH AREA CODE CA X75 3ui dpi -/ Y 3-0 S-/ J BoX �CORPoMTN)N Q INDIVIDUAL Q PAATNEPSMP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATE-AGENCY Q FEDEPALAGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION Q 2 DISTRIBUTOR - RESERVAIF TION IAN *OF TANKS AT SITE E.P.A L O.+(opnmL) Q D FARM ❑ d PROCESSOR d5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonat DAYS: NAME(LAST.FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME T,FIRST) PHONE+WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE+WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME T /6 CPRE OF ADDRESS INFORMATION (ia S -; In (�I.Q� MAILING OR STREET ADDRESS 2 ✓ 0oi b'^Eca* Q INDIVIDUAL Q LOCAL & C STATE AGENCY -O 0X 3/_DI Q CORPORATION Q PARTNERSHIP Q COUNrYAGENCY Q FEDERAL GTY NAME /� STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINGORSTREET ADORESS ✓ �'b1^O"'M Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION 0 PARTNERSHP Q COUNTYAGENCY Q FEDERALAGENCY CITY NAME I STATE ZIP CODE PHONE+WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 it questions arise. TY(TK) HQ F4-F4 - p (J I U & 13, 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: L❑ 11.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT pPPLICANTSNAME(PRWTED&SIGNATURE) APPLICANTSTITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY p COUNTY# JURISDICTION# FACILITY#aa / /TT -5 ,3 S / C/ LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL ISUPVISOR-DISTRICT C E -OPTIONAL CO/ S�CB/ / -6 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONNLLY.. FORFORM A(9.90) 0 •