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STATE OF CALIFORNIA ,[[�` STATE WATER RESOURCES CONTROL BOARD STD 7 - >6 i m ei�� s a° \L UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 1( COMPLETE THIS FORM FOR EACH FACILRY/SITE ` °n�[o.w' MARK ONLY �I NEW PERMIT ❑ 3 RENEWAL PERMIT X 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE e / I. FACILITYISITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) OBAO ACILI NAM NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL I,(OPrONAU CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE 0.1 8DX CA TO INDICATE Q CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE AGENCY' O FEDERAL-AGENCY' DISTRICTS' 'ff vomer of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN s OF TANKS AT SITE E.P.A. 1.D.i(aW W) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS DTI EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) ON i WI A A CODE VS' NAME(LAST,FIRST) PHONE i WITH AREA CODE r I �3- NIGHT : NAME( ,FIRST) U I PHONE i WITH AREA CODE HTS: NAME(LAST,FIRST) PHONE IF WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM CARE OF ADDRESS INF1 R TO MAILING OR STREET ADDRESS ✓buloindUle, INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION D PARTNERSHIP COUNTYAGENCY O FEDERAL-AGENCY CITY NAME STA ZIP CODE PHONE WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NA OF E CARE OF ADDRESS INFORMATION Lopez MAILING ORS REET AD RESS bocbindic" INDIVIDUAL O LOCAL-AGENCY = STATEAGENCY J CY-CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FFDERALAMNCY CITY NAME IST ZIP CODE PHONE ITH AREA CODE 7 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ I4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED 01�✓ bor biMicale SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 11 a SURETY BOND l=5 LETTEROFCREOfT O 9 EXEMPTION O 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: I.❑ II.❑ III.V THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT f OWNER'S NAME(PRINTEDa SIGNED) OWNER'S TITLE DATE MONTHrOAYNFAR - S7'u CVJ i -Y-91 LOCAL AGENCY USE Cli P RLxj 8 COUNTY# JURISDICTION# FACK.ITY# - .\ 3 1 1 .131 LOCATION -CiPT/ONAL CENSUS TRACT# -OPTIONAL gUPVISOR-DISTRICT CODE -OiPTpNAL LOCIA7 - 15 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) /� FOR=3AA7 1V 7 4c7„e� clJY� e�sCG. L /p-Il�9Af L713