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�s " e STATE OF CALIFORNIA e• ��^ STATE WATER RESOURCES CONTROL BOARD s m� -. e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A „� ye �.onr,• COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ O NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OB FACILITY NAME //�vn NAME OF OPERATOR ra u A SS I NEAREST CROSS STREET PARCELIIOPTIONAU CI STATE ZIP CODE SITE PHONE a WITH AREA CODE F I/ BOX TO INDICATE O CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATE AGENCY Q FEDERALAGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR Q pV IF INDIAN A OFT AT SITE E.P.A, L D.A(Optima// Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST,FIRST) PHONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) I PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Om br&m Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION Q PARTNERSHIP Q OOUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ OOAb inEinu Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY 0 CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMP ED)—IDENTIFY THEMETHOD(S) USED ✓ ba br&k Q I SELF-INSURED Q 3ogUARANTEE Q 3 INSURANCE Q A SURETY BOND Q 5 LETTEROFCREDT EV6 EXEMPTION Q 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: 1.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED b SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY• C, /L,�J 06 y/�, _ JURISDICTION FACILITY# � S/ Her-30 S LOCATION -OPTIONAL CENSUS TRACT -OPT SUPVISOfl-DISTRICT CODE -OPTIONAL ,-1�� THIS FORM MOST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 LY. v` FORM A(5-91) FOROMM-5 /