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�eoue 4 STATE OF CALIFORNIA ^. STATE WATER RESOURCES CONTROL BOARD i Y UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "�� as -C�[�i0#H.� COMPLETE THIS FORM FOR EACH F YISITE MARK ONLY 0 1 NEW PERMIT r0r, 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT u 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME / NAME OF OPERATOR ADDRESS l NEAREST CROSS STREET PARCEL#(OPTIONAL) S Zo /v Gra A� CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA S I/ BOX TOINDICATE E]CORPORATION 7-1 INDIVIDUAL O PARTNERSHIP E::] LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESEIF RVADIIAN ON #OF TANKS AT SITE E.P.A. I.D.#(optimal) O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) G /- ONE i}NITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST, PHHOONNEEL/*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) IF/a' PHONE A WITH AREA mm PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION- MUSTE COMPLETED NAME CAGC R OFADDRESS INFORMATION y J LvP— �Fb — Szri MAILING OR STREET ADDRESS ✓ boa bINKIde INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY 19. o 65 ovc 172- 51 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY I:1 FEDERAL-AGENCY CITY NAME STAATTE,. ZIP CODE PHONE#WITH AREA CODE III, TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa b INKale O INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY CORPORATION [--] PARTNERSHIP 0 COUNTY-AGENCY O 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) HO L414]- 3-1�!Fl�� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa binftale E:1 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND = 5 LETrEROFCREDIT I�6 EXEMPTION E-199 OTHER 71 VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is C ked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EW II.V III.D 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 MONTWDAYIYEAR LOCAL AGENCY USE ONLY Q COUNTY# JURISDICTION CIL # ,gi6V4 57 � 7 � _F1 l / Z YYY LOCATION CODE OPTIONAL iCENSUS TRACT# -OPTIONAL SUPVISORDISTRICT CCO, - D OPTIONAL —Z? •7{ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11)OR MORE PERMIT APPLICATION• FORiMuB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL \/ FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR 6 0