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oon e STATE OF CALIFORNIA �s, STATE WATER RESOURCES CONTROL BOARD i -es UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� v; COMPLETE THIS FORM FOR EA FACILrrYISITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED SITE ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEO'F OPERATOR ADDRESS NEAREST CRO STREET PARCEL#(OPTIONAL) 500 S CIN NAME STATEZIP CODE SITE PHONE#WITH AREA CODE S' CA 5205- Box TO INDICATE E-1 CORPORATION 0 INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY I] STATE AGENCY FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optimal) 3 AM 4 PROCESSOR 5 OTHER RESERVATION FR 0 0 OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE it WIT' A RE A COE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0In kale INDIVIDUAL LOCAL-AGENCY STATE AGENCY I�CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE it WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓wxowtl aN INDIVIDUAL O LOCAL-AGENCY STATE AGENCY f�CORPORATION PARTNERSHIP 0 COUNTYAGENCY Q 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 F4]-4]- y 6 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box w IMkad (] i SELF-INSURED O 2 ANTEE O 3 INSURANCE 0 A SURETY BOND 5 LEREROFCREDIT Ellfrl EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless x I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY CmOUNTY# JURISDICTION# FACILITY# L3-y =—m 'v0Acicys LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL ISOR-DISTRICTDE -OPTIONAL .231, 0 2 :t 6 C THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLITION- FORM , LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOROMA-1