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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• F M v o COMPLETE THIS FORM FOR EACH FACILfTY1SITE MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C SED ONE ITEM F__j 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACILITY NAME NAME OF OPERATOR STt r.L c/ ./ 444A3/ ADDRESSNEAREST CROSS STREET PARCEL/(OPTIONAL) 2 3 CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE ywkAm., CA v BOX TO INMATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN X OF TANKS AT SITE E.P.A. L D.Y(MUMMO RESERVATION Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(UST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONIE A WITH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION 5 rmrto%mv/ scc ldx/ F7/ .4 MAILING OR STREET ADDR SS ✓ box binOixWA 1 IDUAL 0 LOCAL-AGENCY a STATE-AGENCY 070 O CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY CITY NAME `t STATE ZIP CODE PHONE#WITH AREA CODE tYlc�Dnl G' S Oif III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOW EP CARE OF ADDRESS INFORMATION 'e QS MAILING OR STREET ADDRESS ✓ box 10 rdm INDIVIDUAL a LOCAL-AGENCY O STATE- AGENCY CORPORATION PARTNERSHIP ED COUNTY-AGENCY 0 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4-F4-1- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED J bobinAcaM I SELFNSURED QoLf GUARANTEE 3 INSURANCE O A!77] URELY BDND O 5 LETTEROFCREDT 6 EXEMPTION CD 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 checked. CHECK ONE I3OX INDICATING WHICH ABOVE ADDRESS SHOULD 9E USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 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 6 SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Sb 3 I& 51irg)w LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR•DI`ryICT CODE -OP770MAL /A, ` THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 0- FORM A(5-91) \ FO10033A3