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STATE OF CAUFORMA << �o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMAT 7 ANEN CLO ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT O S TEMPORARY SITE CLOS E I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) I/-I t-,?& DRAOR ACILI N AIFT NAMEOFOPERATOR a ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) CITY NAME CA• STATE ZIPCA �D s SITE PHO E WITH AREA CODE ✓ wz V Ale— TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q CWMYAGENCY' Q STATE-AGENCY• Q FEDERALAGENCY• 'N wer d UST Ie a public ageny,wrpla the lotlwrp:nn of Superyha of obDISTSICTS' ivblon,secin, or office wAbh operate the UST TYPE OF BUSINESS Q t GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.a(optional) 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION Ofl TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•#pdonal DAYS:NAME(LAST,FIRST) PHONE#WITHEACODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE ao9 — / NIGHTS: NAME S .FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME _ _ CARE OF DRESS INFORMATION "//�� 13, MAILINOQBSd. ADOR SS / ✓ Dox binC'rate �Q INDIVIDUAL Q LOCA4AGENCV I Q STATE- AGENCY _,TTJJ /IfP Q CORPORATION Q PARTNERSHIP Q COUNfV-AOENCy Q FEDERAL-AGENCYCITY NA STATE DE P ZIP�� aE#WIT AR ( EA C oQ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW�NE�R..> �'+� `�-�✓/ L . CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS J box bbUbat Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORAPON Q PARTNERSHIP Q COUNTYAGENCY Q FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ lbv birdeaie Q I SELF INSURED Q 2 GUARANTEE IQ 3 INSURANCE Q 5 LETTER OF CREDIT Q A SURETY BOND Q 5 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: L[_—] 11 D) THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 8SIGNED) OWNER'S TITLE DATE MONTWDAY/VEAfl LOCAL AGENCY USE ONLY T COUNTY# JURISDICTION# ACILRY "r ® 371 LOCATION CODE -OPTIONAL CENSUS R i- L SUPVISOR-DISTRICT NAL ' )/ 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(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS9/ 7� /o- 9 �LW FOn061tAT