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c'pOR ° STATE OF CAUFORNIA �^ s STATE WATER RESOURCES CONTROL BOARD +° UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A C. ' COMPLETE THIS FORM FOR EA FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ev 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS p E ONE ITEM �❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA 011 FACILITY NAME ' /� /_ M�r,n-&i NAME OF OPERATOR E✓ ) 35 �I /Na ,)e_ `gDad NEAREST CROSS STREET PARCELA(OPTIONAQ CITV N ESTATE ZIP CODE SITE PHONE#WITH AREA CODE /jn CA TOOIN Box O CORPORATION INDIVIDUAL =PARTNERSHIP l�LOCALDISTRI-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#fopfional) RESERVATION 3 FARM 0 4 PROCESSOR [—] 5 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE-�ITH AREA COOP Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindic a INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY O CORPORATION PARTNERSHIP Q COUNTYAGENCY 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 blMloam INDIVIDUAL O LOCAL-AGENCY STATE AGENCY l�CORPORATION 0 PARTNERSHIP COUNTY-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 4 4 - 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box IoindicM O 1 SELF-INSURED UARANTEE O 3 INSURANCE O X SURETY BOND O 5 LETTER OF CRECrr EW6 EXEMPTION O N OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. CHECKONE 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY //77 T 4 COUNTY# ct JURISDICTION# FACILITY# 01 2a FT71 LOCATIONC TIONAL CENSUSTRACT# -OPTfO/W� SUPVIeOR-DIST OE -OP710NAL 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 AIS-91) ` l L/FO�R6633A-5 h,/