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�. a ' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EA H FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Cbl,Jese NoorAtp- pct ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 3 08' B e I-favi+ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE .1 BOX Sick-40ji CA TO INDICATE (]CORPORATION D INDIVIDUAL =PARTNERSHIP (]LOCAL-AGENCY 0 COUNTY.AGENCY O STATE-AGENCY O FFDEML-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN 11OF TANKS AT SITE E.P.A. I.D.*/optimal) Q 3 FARM Q 4 PROCESSOR Q RESERVATION 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHnNP I WITH AREA NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Eox bbgbaN = INDIVIDUAL E71 LOCAL-AGENCY O STATE-ACENCY x le c/6 (]CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGEWY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE C4 ?5120f- 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER 61e- CARE OF ADDRESS INFORMATION a 1'+ MAILING OR STREET ADDRESS ✓ box 0INIcale INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY I�CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#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-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box b Wicale O 1 SELF-INSURED2 GUARANrEE (]3 INSURANCE A SURETY BOND O 5 LETTER OF CREDIT 6 EXEMPTION 0 93 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.❑ IL[if III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR INTED a S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# # C'f�/n�F3�7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAU z3,8� 323 /OS ! 147 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A 5 -