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STATE OF CALIFORNIA cc`• STATE WATER RESOURCES CONTROL BOARD i a Vr1 UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A =; �J COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5/5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) V7 OBA OR FACILITY NAME NAME OF OPERATOR I>E 5 Ef20 S ADDRESS ^^ r� NEAREST CROSS STREET PARCEL 0(OFrIONAO CITY NAME STATE ZIP COC� O SITE PHONE#WITH AREA ODE LORI J ✓ Box TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL GENCY C—] COUNTY-AGENCYf� STATE-AGENCY Q FEDERAL-AGENCY DISTRI TS TYPE OF BUSINESS O I GAS STATION ❑ 2 DISTRIBUTOR Q / IF INDIAN RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS DIVE(( EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 9-S NIGHTS: NAM (L T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) AI y PHONE A WITH AREA CI II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION S4046' A5 EAU( LTU MAILING OR STREETAODRESS ✓ bwbiM"% D INDIVIDUAL a LOCAL-AGENCY a STATE-AGENCY Q CORPORATION I= PARTNERSHIP O COUNTY AGENCY O FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION A5 FAGtut MAILING OR STREET ADDRESS - ✓ L#v bhMkate O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY O CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ F4-[-4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ do:to indicate I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SUR Efl BOND D 5 LETTEROFCREDR ®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. II.❑ 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 CSODUNNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS T?A ^•OPTIONAL SUPVISOR-DISTRI 700E -OPTIONAL 1 I THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FORW33A 5