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�soun es <br />STATE OF CALIFORNIA 49 <br />STATE WATER RESOURCES CONTROL BOARD sa <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W.�� �0 <br />• C�(IfOR N1 <br />COMPLETE THIS FORM FOR EA FACILITYISITE <br />MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT Ev 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA qnACILITY NAME Sy <br />SDimco <br />NAME OF OPERATO <br />DAYS: NAME (LAST, FIRST) <br />Alkyd c �n <br />ADD7// W , '1� M7 <br />NEARrTREET <br />PARCEL # (OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP CO <br />SITE PHONE S WITH AREA CODE <br />CA�Z-�� <br />LOCATION CODE - OPTIONAL <br />CENSUS TRACT # - OPTIO AL <br />✓ BOX <br />TOINDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS i GAS STATION 2 DISTRIBUTOR✓ <br />IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />I <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARYI - ontionai <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II- PROPERTY OWNER INFORMATION ofM[IST RF COMPI FTFI)1 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box b indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />CORPORATION Q PARTNERSHIP COUNTY -AGENCY (] FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III- TANK OWNER INFORMATION - (MUST RE COMPI FTFDI <br />NAME OWNER <br />t4 A <br />)0Hr-6)A,9am Ar®d ucJ-s <br />CARE OF ADDRESS INFORMATION <br />MAIL&O OR STREET DRESS <br />✓ box b indicate INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY <br />E0 <br />CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CIN NA <br />STATfi+ w <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />-719 <br />LOCATION CODE - OPTIONAL <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (TK) HQ4 4 - Q 0 <br />V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. D II. 0 III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # # <br />JURISDICTION # <br />FACILITY # <br />LOCATION CODE - OPTIONAL <br />CENSUS TRACT # - OPTIO AL <br />SUPVISOR -DISTRICT CODE - OPTIONAL <br />0--5,-2-2 <br />21 <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORMA (9-90) <br />FOR0033A-R2 <br />r <br />