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I I �Sau" es STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATI 0N- FORM A "� a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 0 1 NEW PERMIT Q 3 RENEWAL PERMIT ff 5 CHANGE OF INFORMATION E—] 7 PERMANENTLY CLOSED SITE ONE ITEM 71 2 INTERIM PERMIT a 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE r0_7 I I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) i DBA OR FACILITY NAME NAME OF OPERATOR Seo G�`�"o 1J �CCoiE'D ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ✓ �STD�-I—To�l ICA T!Zo Z �zva) 4�3 -639 TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY DISTRICTS Q FEDERAL-AGENCY TYPE OF BUSINESS 0 t GAS STATION = 2 DISTRIBUTOR RESERVATION✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) w Q 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS C JV D O'1 9V7_ 7 7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 14jEN ! IN 6- S'30/;? NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME � TO/� RFGo CARE OF ADDRESS INFORMATION S MAILING OR STREET ADDRESS � G� ✓ box IDindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE CA 4SZo 7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION e/f'F_ >=c v p_D MAILING OR STREET ADDRESS ✓ box IDindicats Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 3C) C - 1� 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) HO F41_4]- V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and 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: I. II.a III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY Y# JURISDICTION# FACILITY# F 10 10 / l M-7 -7SToG/< S3 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 0 2-31islo 32-3 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 A(9-90) FOR0033A-R2