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^ePoen ; cu STATE OF CALIFORNIA ,� STATE WATER RESOURCES CONTROL BOARD Qm� n a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA C��,nOPN�n COMPLETE THIS FORM FOR EACH LrTYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME a NAME OF OPERATOR / u v SPS ADDRESS NEARESTCROSSSTREET PARCEL#(OPTIONAL) 00 5- r� U - CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA CODE Sk c/E .r CAI/ BOX J-o TO INDICATE LY1 CORPORATION E-1 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION DISTRIBUTOR / I❑ RESERVATION V IF INDIAN A OF TANKS AT SITE E.P.A. I.D.%(optimal)3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•opllonal DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) ea Se 7- 37 ' slo b PHONE It WITH AREA C011F NIGHTS: NAME( T,FIRST) PHON %WaH AREA CODE NIGFiTS: NAME(LAST,FIRST) /( I( (rIF II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STR ADDRESS `�bW binEkale 0 INDIVIDUAL O LOCAL-AGENCY OSTATE-AGENCY 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Wxbindkab INDIVIDUAL Q LOCAL-AGENCY STATE AGENCY 0 CORPORATION PARTNERSHIP E�j COUNTYAGENCY 0 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 4 4 -101.21 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE M HODS) USED ✓Cox b intlkae O 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE Q 4 SUREIYBONO 5 LETTEROFCREDIT 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE 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 TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY% JURISDICTION N FACILITY u it ot -( y11101116'1 go LOCATION CODE -OPTIONAL CENSUS TRACT% -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL O/ 3 3 ;L3 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) FOR^0033A 5