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eepOuw STATE OF CAUFORMA ti STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e •e Y/.. p °4nown.. COMPLETE THIS FORM FOR EACH FA&rryisrm MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ T PERMANE SED 3 ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE S2 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR &/2 Aqgio e,0- ADDRESS NEAREST CROSS STREET PARCELI(OPrgNAU CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE 5/v C' CA 4S U - cl - s TOINDICATE a COR TION O INDIVIDUAL O PARTNERSHIP O LOCALACOM O COUNTYAGENCY Q STATE-AGENCY O PEDERALAGENCY TYPE OF BUSINESS L GAS STATION ❑ 2 DISTRIBUTOR = .1 IF INDIAN s OF TANKS AT SITE E.P.A. 1.0.A(aWlaW RESERVATION 3 FARM 6 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE V WITH AREA CODE DAYS: NAME(UST,FIRST) NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓iw alltlkri ID INDIVIDUAL Q UXAL-AGENCY Q STATE-AGENCY 0 CORPORATION Q PARTNERSHIP E:3 COUNTY,AGENCY 0 FEDERALAGENCY CITY NAME STATE TJP CODE PHONE a WITH AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Lw 0V iCM INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY =CORPORATION O PARTNERSHIP COUNTYAGENCY FEDEPALAGENCY CITY NAME STATE LP CODE PHONE x WITH AREA CODE IV.BOARD 0 IZA UST STORA E ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) 0 4 4 - V. PETROLE ESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Om NYWk� Q 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE Q A SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION %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: I.Q 11.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTHIDAWVEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILrTY• Sel"'9S3-0 m LOCATION CODE -67 CENSUS TRACT a-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3 00 9/'7-3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY. FORM A(5+91) '011M A5