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a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION K7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACILITY NAME NAME OF OPERATOR ADDR SS NEAREST C1kOSS STREET PARCEL#(OPTKNiAu I CITY NAME STATE ZIP ODE SITE PHONE#WITH AREA CODE L-43 dL CA GY ✓ Box TOINOCATE 0 CORPORATION E=I INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aPamal) 3 FAR 0 PROCESSOR 5 OTHER RESERVATION ❑ O OR TRUST LANDS EMERGENCY CO CT 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) PWQNP WITH AREA CODE- 11. PROPERTY OWNER INFORMATION-(MbQT BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ b0bindkM E:1 INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER IT OF ADDRESS INFORMATION MAILING OR STREET ADDRESS xW17 = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY 0 CO PA77ON = PARTNERSHIP (]COUNTY-AGENCY 0 FEDELIL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Iv.!B EQklAL+Z 4i1AN US�STAR ACCOUNT NUMBER-Call(91 )323.9555 if questions arise. CT (TK) HO F4-T4]- V. 4 - 3 a V. PETROLEUM UST FINANCIAL R NSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓ box bkdb O 1 SELF-INSURED =2 GUARANTEE E71 3 1NSURANCE A SURETY BONG 5 LETTEROFCREDIT 6 EXEMPTION O N OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner uynless box I or II is checked. es CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.IX 11.O III.O 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY OODUUNTTY# JURISDICTION# FACILITY om/# LOCATION COD -OPTIONAL CENSUS TRACT# -OPT NAL SUPVISOR-CISTflK:T CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IN ONLY. FORM A(5-91) /A FOR S L/ �• C//(///