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,�Q/r�G1 : �lea� CP��in-gam � Gi�rn�;�✓ � r�l� -Nc.e ��.�t STATE OF CALIFORNIA • `+ou+ �� i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A iYf , GCOMPLETE THIS FORM FOR EACH FACILffYISRE MARK ONLY 1 NEW PERMIT S RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CL ED SITE ONE ITEM Q 2 INTERIM PERMIT Q d AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OBAOR FACILITY NAME NAME OF OPERATOR AOORESS NEAREST CROSS STREET P4CELf(OFF0RAL) M CITY NAME STATE ZIP CODE S172 HDA r WITH AREA CODE CA n15 C C1 s TO INDICATE ]CORPORATION ] INDIVIDUAL PARTNERSHIP (] LOCAL AGENCY ] COUNTY-AGENCY DGTPoCTS I] STATE-AGENCY I] FEDERAL-AGENCY TYPE OF BUSINESS 1 =STATION O 2 DISTRIBUTOR O ✓ IF INDIAN II OF TANKS AT SITE E.P.A L 0.d(optMai) /1 Q 7 FARM O d PROCESSOR Q 5 OTHER OR RESERVATION TRUST LANDS 1J EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional GAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE DAYS: NAME( FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAMECARE OF ADDRESS INFORMATION c MAILING OR STREET ADDRESS ✓ box bYtlkpl INDIVIDUAL ] LOCAL-AGENCY ] STATE-AGENCY '.0, ]CORPORATION ] PARTNERSHIP ] COUNTY-AGENCY ] FEOERAUAG'cNCY CITY NAME STA ZIP CODE PHONE d WITH AREA CODE EL CFP_?_l7n G s o HK III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET AII)rE ✓ 00[bMcaA ] INDIVIDUAL ] LOCAL-AGENCY ] STATE-AGENCY ( \ (D ]CORPORATION �PARTNERSHIP COUNTYAMNCY Q FEDERAL-AGENCY CITY NAME STATE LP CODE P NE s WP AREA CODE n 2 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 it 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 or II is checked. CHECK ONE 00X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.G III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY ® COUNTY# JURISDICTION# FACILITY# j9' CoMP11TE.'2 n)o, [� L I I II / Iq C� LOCATION�'E *OPTIONAL 3Q US T�T a -OPTQIONAL S� ISOR`DISTRI�CODE •OPTIONAL �I DHT IM1T7 I 2z 7��$1 THIS FORM MUST BE ACCOMPANIED JBY AT LEAST(1)OR MORE PERMIT APPLICATION• FO UNLESS UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(490) \ FCRDMIA 12 SNL