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! STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �^ o' COMPLETE THIS FORM FOR EAC FACILRYISITE� MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ g TEMPORARY SITE CLOSURE / v/ I FAf'II rTVMITC IAICMOAAATInu a .--..- DBA OR FACILITY NAME Coe. d ti NAMEOFOPERATOR 4A -C LMbh*M Q INDIVIDUAL Q LOCAL -AGENCY O STATE -AGENCY p CORPORATION O PARTNERSHP p COUNTYAGENCY p PEDERAWIGENCY ADDRESS 7� NEAREST CROSS STREET PARCELI(OPTIOW 42J, CITY NAME - c�r 9TATE ZIP CODE SITE PHONE 0 WITH AREA CODE CA cl SZpv . BOX TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP E3 LOCA4AGENCY Q COUNTY -AGENCY Q STATE -AGENCY O FFDERALAGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTORO '/IF INDIAN A OF TANKS AT SITE E. P. A. L D. A jcPt mW) Q 3 FARM Q A PROCESSOR Q S OTHER RESERVATION I OR TRUST LANDS eMtNUtNOT UUF ADI PtHSUN (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE DAYS: NAME (LAST, FIRST) PH ONF (WTH dPFd COfIF NIGHTS: NAME (LAST, FIRST) PHONE A WITH AREA CODE NIGHTS: NAME (LAST, FIRST) A II. PROPERTY OWNFR INFO RAA ATIAN. /NAI ICT RD r'OKADI FTCnI NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS LMbh*M Q INDIVIDUAL Q LOCAL -AGENCY O STATE -AGENCY p CORPORATION O PARTNERSHP p COUNTYAGENCY p PEDERAWIGENCY CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE 111. TANKOWNFR INFORMATHIN.IMI ICTRccAMolcTcrn NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ tImb.6b = INDIVIDUAL Q UXAL-AGENCY STATE -AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY#GENCY FEDERAL,AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE IV. DUAnU ur LUUALr[AL1UN U,1 51 UHAUt htt AGUUUNT NUMBER - Call (916) 323.9555 if question BASE. TY (TK) HO 4 74- Z { 5 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED)— IDENTIFY THE METHOD(S) USED ✓ w n IM¢aIe O I SELF-INSURED L-1 2 GUARANTEE 3 INSURANCE Q A SURETY BOND 5 LETTEROFCREDT = A EXEMPTION (] W OTHER VI. 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: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT LUUAL AUtNL.Y USt UNLY COUNTY# JURISDICTION# FACT® 3ti 6666,0 b Y LOCATION CODE - OPTIONAL CENSUS TRACT • - OPmm4L SUPVISOR •DISTRICT CODE - OPTIONAL U/ 'z3ju 3 z 5Ccs 3/1/9 3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FORM B, UNLESS THIS ISA HANGE OF SITE INFORMATION ONLY. FON0033A 5