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STATE OF CALIFORNIA - STATE WATER RESOURCES CONTROL BOARD iJ u UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ro> . O�x1�uPM� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR lba¢ 1'a Gi N ADDRESS NEAREST CROSS STREET PARCEL N(OPLIONAL) /.22-S CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE BOX CA TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY O COUNTY-AGENCY STATE AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS F7 1 GAS STATION F-1 2 DISTRIBUTOR O '/RESERVATIIF INDION AN 4 OF TANKS AT SITE E.P.A. I.D.%(optimal) 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME /imt t �M .v CARE OF ADDRESS INFORMATION MAILING CFA STREET ADDRESS I box b Indicate OINDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY a- 6371 STAO CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CI NAME TEZIP CODE PHONE%WITH AREA CODE d�k ,� sus III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME Pf OWNER CARE OF ADDRESS INFORMATION �S MAILING OR STREET ADDRE ✓ Wx Xindbate O INDIVIDUAL O LOCAL-AGENC 0 STATE AGENCY O CORPORATION Q PARTNERSHIP 0 COUNTY-=Y D FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. TY(TK) HQ 4 4 -ET:F]-:]= V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box b indicate 0 1 SELF-INSURED0 GUARANTEE (] 31NANCE D A SUflE Y BOND SUR D 5 LETTER OF CREgi 6 EXEMPTION D 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is hocked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ IL III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPUCANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION% XI LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRIC T CODE -OPT/ N L 3 So 3�3 O C THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FORD033A