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bb 0„w STATE OF CALIFORNIA e ` STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A W m� "° I e 'Y/ p °4,.onN n COMPLETE THIS FORM FOR EACH FACILITYISTTE MARK ONLY O I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM = 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE Z I. FACILITYiSITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OBA�iACiLITV NAME _� �' NAME OF ERATOR ADDR S _ 'I pa / NEARES CROSS STREET PARCEL#(OPTIONAL) O! o 70 2d of dw CITY NAM STATE ZIP CODE SITE NE WITH AREA CODE CA 2v�f 1 - TO I/ BOX O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCYDT0 COUNTYAGENCY O STATE-AGENCY 0 FEDERALAGENCY TYPE OF BUSINESS = YUS STATION 0 2 DISTRIBUTOR RESERVATION NOF TA AT SITE E.P.A. I.D.A(gNimap ,Ese- 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE4-WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bW bM9bo4 OINDIVIDUAL LOCALAGENCY STATEAGENCY =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O 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 ✓ ml 0 imbm O INDIVIDUAL a LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION PARTNERSHIP D COuNrYAGENCY 0 FEDERAL-AGENCY 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 ET-- V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓5M binEkaa 0 1 SELF-INSUREDO GUARANTEE 0 3 INSURANCE O 4 SURETY BOND 5 LETTEROFCREDIT a EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.= III. THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PR WTEO A SIGNATURE) APPLICANTS TITLE DATE MONTWOAYIYEAR LOCAL AGENCY USE ONLY COUNTY a 4'JURISOICTION a FACILITY a UZN't' LOCATION CO TTONAL C25.0 2 OPTTOAML SUPVISOR-DISTR�TCODE - CPTXfttr- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM BB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, T� FORM A(&91) FORW37A-5 lJ�