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STATE OF CALIFORNIA ^, i STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�ffi COMPLETE THIS FORM FOR EACH FACILITYISITE �.,„o��,.' MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT E-] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT d AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE /J I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) L— DBA ORFAC ITy1JAME NAME OF OPEMTOR 1 �^ . ADDRESS i NEARESTCROSS STREET PARCELe(OPTCeAU L CITY NAME V —ocki-- AZ. !J CA /_o STATE ZIP / Ee WITH AREA CODE � >b TO INDICATE ED CORPORATION p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTY,1ENCY' p STATFwENCY' P owner of UST h a public agency,oorrplete the Id DISTRICTS p F®ERAL,1fENCY' lowing:nartw d Superv'sor d o"lon,section,W Office which aWWW the UST TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 1 OF TAROKS A7 SITE E.P.A. I,p,a(gyimaq 'N�[_3 FARMRESERVATION A PROCESSOR ❑ 5 OTHER OOR TRUST LANDS j1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:M �F[R” PV�ONE+WITH AREA CODE DAyg: NAME LAST,FIRS/ ,Ju�.I �). t T) PHONE 0 WITH AREA CODE NIGHTS:MM %PHONE I WITH AREA CODE NIGHTS: MME(LAST,FIRST) PHONE I WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED MMS-( CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS C ✓ eov bMkals p INDIVIDUAL p LOCAL-AGENCY p STATE-AGENCY -v o / p CORPORATION p PARTNERSHIP p CWNry viENCy p FEDERALAGENCY CITY�GAME STA ZIP CODEO� PHONE 1 WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER I CARE OF ADDRESS INFORMATION M IAO STREET�A7DDRESS ✓bmbNNesb p INDIVIDUAL p LOCAL AGENCY p STATE-A(ENCY . 3D y p CORPORATION p PARTNERSHIP p COUNTY-AGENCY p FEDEMLAMENCY CITYL ONE E STATE ZIP CODE PHI WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-F4--]- V. 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ 1 SELFINSURES p 2 GUARANTEE p 3 INSURANCE p A SURETY BOND p 5 LETrEROFCREOIT p 6 EXEMPTION p 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 USEDFOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.[=] Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTKOAY/YEAR LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I FACILITY t /%/-„ LOCATION CODE -OPTGONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIOAw C THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 11 JJFgWW3A{IT J-� I( L'(`'I