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(TATE OF CALIFORNIA STATF WATER RESOURCES CONTROL ROARO �, n� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o' G COMPLETE THIS FORM FOR EACH FACILrTYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT d 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR i9a,le O _ ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 3qla 5, E71 .k CITY NAME STATE ZIEICODE SITE PHONE*WITH AREA CODE Irl–fm k+tm.JI CA 9526 TI/ BOX D CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY DISTRI TS TYPE OF BUSINESS = t GAS STATIONRESERVATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optionat) Q 3 FARM O 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) 6(t_t%A WIa 209-17411 PHnNP ff WITH ARFA CODF—_ NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA COOP It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION . N _i<1trN _ MAILING OR STREET ADDRESS ,,��✓,,LLw�xbl INDIVIDUAL LOCAL-AGENCY ESTATE-AGENCY Q 0 LLn:uRPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY E] FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 01 III. TANK OWNER INFORMATION- (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bINIOM 0INDIVIDUAL 0 LOCALAGENCY STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP O COUNTYAGENCY 0 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 - z Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box lo indicate 0 I SELF-INSURED 0 2 GUARANTEE I= 3 INSURANCE 0 4 SURETY BOND O 5 LETTER OF CREDIT 0 6 EXEMPTION 9B 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.❑ U.VIII.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY��# JURISDICTION# FACILITY# I-SHI LOCATION CODE -OPTTIIO--N``A--L11---�' CENSUS TRACT# -OPTIONAL SUPV130R-DISTRICT CODE -OPTIONAL 22 13 . 8a 2 7 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. \. FORW33A 5 FORM A(5-91)