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BW^ t STATE OF CALIFORNIA e i STATE WATER RESOURCES CONTROL BOARDy_ '; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° `L� ya v Ont,�OYY•n COMPLETE THIS FORM FOR EACH F ILITYISRE FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NA ^- ' MEOFOPERATOR !� ADORESt NEAREST CROSS STREET PARCEL O(OPTIONAL) lkv_6>9 /4rlP,1141N( 5 AD. CITY NAME STATE ZIP CODE ITE P ONE a WITH AREA CODE /-OAZ CA z6-vel I/ BOX TO INDICATE 0 CORPORATION Q INDIVIDUAL 0 PARTNERSHIP 0 LDCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDEMLAGENCY DISTRICTS TYPE OF BUSINESS ❑ / GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN MOF TANKS AT SITE E.P.A. I.D.Y(optional) RESERVATION , ❑ 'Z 3 FARM 0 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS � L� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional OAVSUNAMJ:UAST,FIR PHONE.�WITHA,REAGODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA ICODEDE/ NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME4-147- irvbpli CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS � n^ ✓ box b NICAA O INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY /2 fi?q A Xa� 91 /VJ• =CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY CIN NAME STATE,a ZIP CODEPHONE s 1�I�rA' CO �DE , Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) uVL ) !A NAMEOFO ER CARE OF ADDRESS INFORMATION Y `-- - Yon4 MAILING OR STREETADDRESS '7 ✓ box bindb NDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY D• y/ 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME � STATE i ZIE PHONE;1 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 METHOD(S) USED ✓box bintlbau 0 I SELF INSURED O 2 GUARANTEE 0 3 INSURANCE 0 A SURELY BOND O 5 LETTEROFCREDT 0 6 EXEMPTION O W OTHER 71 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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR LOCAL AGENCY USE ONLY COUNTY 0 JURISDICTION A FACILRY x LOCATION CODE -OPTIONAL CENS'US�FiA� OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 9 JJ G4 V1 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(5-91) - / FOR0033A 5 IW7- 70`50;2` 'Ay