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1 STATE OF CALIFORNIA i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION " FORM A "�� e °.,,.u..,. COMPLETE THIS FORM FOR EACH F LITYISITE MARK ONLY ❑ I NEW PERMIT ❑ S RENEWAL PERMIT 02-<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 IN A AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE O I. FACILffYISIT NFORMATION&ADDRESS-(M OST B OMPLETED) DBA OR FACILITY N E ^ NAMEOFOPERATOR ADDRESS /vv�•l/•-Cw NEAREST CROSS STREET PARCEL 0(OPTIONAL) CITU NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE CA 9�37 1 6 3- - 6G 9Y TO INMATE p CORPORATION p INDIVIDUAL p PART RSHIP p LOCALAGENCY p rouNTY.AGENCr OSTAICTs Q STATE-AGENCY p FEDERAL AGENCY TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.a(opimaD Q 7 FARM Q ! PROCESSOR 0 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAMT,FIRS n PHONE=WITH SRA`f.ODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST FIR T) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH APPA P.Mg II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Om bllbipY p INDIVIDUAL p LOCAL-AGENCY p STATEdcENCY Q CORPORATION p PARTNERSHIP p COUNTYAGENCY p FEDERAL- AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS box bAbbba p INDIVIDUAL p LOCK-AGENCY O STATE AGENCY p CORPORATION p PARTNERSHIP p COUNTY-AGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATIOONN LIST STORAGE FEE ACCOUNT NUMBER"Call(916)323.9555 if questions arise. 4 TY(TK) HQ 4 A -�&j_I ZJ V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓bm bkdl p I SELF-INSURED p 2 GUARANTEE p 2 INSURANCE p 4 SURETY BOND p 5 LETTER OFCREDIT p 6 EXEMPTION p 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank ow unless 4011 ot II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING L I Q IN.GI THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY I(NOW E,IS TR O CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY o4-7JURISDICTION x FACILITY 0 10 O o u LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL. SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PER APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR9W3A-5