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/ bOJM STATE OF CALIFORNIA - b� STATE WATER RESOURCES CONTROL BOARD f rt ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� me Ob N.N COMPLETE THIS FORM FOR EACH FACILfTYISITE MARK ONLY 0 1 NEW PERMIT F—] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Z PERMANENTLY CLOSE E ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE U I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME 1 NAME OF OPERATOR �oX MIs `haJ(oi ev ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL, 2Si0 Al. C4 ,i I CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE _ gk=N= k-61-1 CA szo ✓ BOX CORPORATN)N � INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTYAGENCY (71 STATE-AGENCY O FEDERAL-AGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION2 DISTRIBUTOR > RESERVATION 11 OF TANKS AT SITE E.P.A. I.D.#Topbonap 3 FARM O 4 PROCESSOR IJ 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) PHONE 8 WITH AREA nonp NIGHTS: NAME(LAST,FIRST) PHONE—#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA COOP H. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ` �C 5 C 5 ` r CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓wxblr&W 0 INDIVIDUAL ED LOCAL AGENCY [1:1 STATE-AGENCY III r(O S A G l 1 (/L I T E=1 CORPORATION 0 PARTNERSHIP COUNTYAGENCY 11 FEDERAL-AGENCY CITY NAME STATE ZIP GODE PHONE#WITH AREA CODE S�mc � Cc III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 94;mc IS --pf— MAILING OR STREET ADDRESS ✓ box biWKab F—] INDIVIDUAL LOCAL-AGENCY (] STATE AGENCY CORPORATION O PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ box mintlicale n 1 SELF-INSURED =1 2 GUARANTEE 0 3 INSURANCE #SURETY BONG 0 5 LETTEROFCREDT 11 6 EXEMPTION = W OTHER VI. 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: L O II. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# �'l - - - 3 0 LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL 7//le,L[ /` Q 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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND TORAGE T NK REGUJJccATIONS C � P�� FoaooaaA.Rc