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`41 ��eou• e STATE OF CALIFORNIA `t STATE WATER RESOURCES CONTROL BOARD : �o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A _�`� �, o .,.o'�. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ r NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) �Z5 Af 1 025- r 70- zO -o CITY PAME STATE ZIP CODEITE PHONE#WITH EA CODE Gr�G"� CA 1 3 - oo BOX TOINDCATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS f-1 1 GAS STATION 2 DISTRIBUTOR ❑ */ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oprlanal) flESERVATION 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS E ERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE�WITHAR ACaOD_E _ DAYS: NAME(LAST.FIRST( NIGHTS: N E(LAST, (RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION p MAILING OR STREET ADDRESS ✓boa b MaicM INDIVIDUAL 0 LOCAL-AGENCY O STATE.AGENCY V/ CORPORATION PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITY KAaE STATE ZIP CODE PHONE#WITH AREA ICODE- G#JY� tel/ Gr✓�0�./ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS eoa bintlbab INDIVIDUAL E71 LOCAL-AGENCY Q STATE-AGENCY 14A24 CORPORATION D PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY CI ME STATES ZIP CODEPHONE�WITHA ACODE O IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--.CYalll(916)323.9555 if questions arise. 33 TY(TK) HQ 7441- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eor bindkale O I SELF-INSURED 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND D 5 LETTEROFCREDIT O S 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.❑ H.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PA INTED&SIGNATURE) APPLICANPS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# Sq LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3, F� 9 T1 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) FOR0033A-5 A/