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Ou. STATE OF CALIFORNIA J 4, STATE WATER RESOURCES CONTROL BOARD s .�q j UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� y: Cr4r COMPLETE THIS FORM FOR EACH FACILrrYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMABgNTI,Y CLOSED SIE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /f I, FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY AME NAME OF OPERATOR ADDRESS ) -^ _s NEAREST CROSS STREET PARCEL#(OPrONAL) CITY NAME ISL_/11 #ilhVlT` STACA ZIP CODE_ `M^ SITE PHONE a WITH AREA CODE TO./ BOX O CORPORATION O INDIVIDUAL Q PARTNERSHIP a LOCAL-AGENCY l� COUNTY-AAGEENNCYi/ O STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR ❑ q V 11 IND oN a OF TANKS AT SITE E.P.A. L D.a(optional) 3 FARM 0 4 PROCESSOR EV<5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bxbuWkaD Q INDIVIDUAL Q LOCAL AGENCY O STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY ED 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 ✓ boa0 mica# Q INDIVIDUAL O LOCAL-AGENCY (]STATE AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY 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 F4-1-4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa b WIata a l SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE Q A SURETY BOND 5 LETTEROFCREDIT 6 EXEMPTION (] 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.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR WTED B SIGNATU RE) APPLICANTS TITLE DATE MONTWOAYtYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m 010 LOCATION CODE -OPTIONAL (CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)On MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5.91) I FOROMA-5 l — C\ 14.1 /��C{