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^usouw � STATE OF CALIFORNIA `* STATE WATER RESOURCES CONTROL BOARD f UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A "m� COMPLETE THIS FORM FOR EACH CILrTYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY-CLOSE/_ D SITE ONE RL! EM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 13 An) K o7� 5 c ADDRESS '�IY111AEISTCROSS STREET PARCEL 0(OPFIONAL) L 2 CP CITY NAME STATE IP CODE SITE PHONE#WITH AREA CODE S f0 G CA �dS TOBoINDICATE O CORPORATION C-1 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION »OF TANKS AT SITE E.P.A. I.D.#(oplla i) 3 FARM Q d PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NtkME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ao l- NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) r I ( I II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME t r 1O CARE OF ADDRESS INFORMATION MAILING TREET ADDRESS I ✓ hatblMicN# E3 INDIVIDUAL =1 LOCAL-AGENCY 0 STATE-AGENCY / 0r / � ' E-1CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITU NAIJE_fD P STATE„L ZIP10E PHONE sWITH AREA CODE I PO III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS - ✓ WX0imkm# Q INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY O CORPORATION Q PARTNERSHIP Q COUKIY-AGENCY Q 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 44 - O a3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓EOA bYWkaN O I SELF-INSURED O 2 GUARANTEE Q 3 INSURANCE O A SURETYBOND 5 LETTEROFCREDT 6 EXEMPTION 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 BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL❑ III.❑ 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY s r COUNTY N JURISDICTION x FACILI LOCATION CQDE - PTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MOST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \0.� �FORM A(591) 5- �� YR� FCR9077A3