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't60JA f f STATE OFCALIFORNIA s STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERZIACILITYtSITE PLICATION - FORM A i °op y COMPLETE THIS FORM FOR EA MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE _ I. FACILITYISITE INFORMATION III,ADDRESS-(MUST BE COMPLETED) DSA OR ILITYNAME _ Y n� N J NAME OF OPERATOR ADD $ / u�/-,nl�/ _/1 /✓(9 ' '/ NEAREST CROSS STREET PARCEL#(OPIONAu CITY N//AME k— I O n /A//, // n (M/Jam` STATE ZIP CODE- 5�D SI oyPHONE-X WITHT5/A DE ✓ BOX �L/ TOINDICATE O CORPORATION 0 INDIVIDUAL I�j PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY STATE AGENCY (] FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#NPUMal) RESERVATION F-13 FARM ❑ 4 PROCESSOR ❑ 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA COI II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bor bintlk9e = INDIVIDUAL Q LOCAL-AGENCY L—1 STATE-AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box Wicale INDIVIDUAL D LOCAL-AGENCY Q STATE-AGENCY I�CORPORATION O PARTNERSHIP COUNTY-AGENCY 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 F-4141- V. 4 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED ✓ bwbirdkale I SELF-INSURED O V6UARANTEE = 3 INSURANCE 0 4 SURETY BONG I�5 LETTEROFCREDIT 6 EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or Ills checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ I.❑ 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 MONTH/DAWYEAR LOCAL AGENCY USE ONLY COUNTY# � / JURISDICTION# FACILITY# M A /6 & alpal LOCATION CODE -O I L CENSUS TRACT# -OPTIO Q SUPVISOR-DISTRICT CODE -OPTIONAL 122- 1 THIS FORM MUST a ACCOMPANIED 1Y AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. FORM A(5-91) FOR6033A-5