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STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A/4 COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION l ERMANENTLY ri QSEDITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE CO PLETED) DBAOR FACILITYE NAMEOFOPERATOR k- 61' F6kg9(r ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) �l AVE14 CITU NAME 9TATEZIP CODE / SITE PHONE♦WITH AREA CODE v BOX PG 0 CA TOINDICATE O CORPORATION Q INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY Q COUNTYAGENCY 0 STATE AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O / GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. 1.D.x(optional) RESERVATION O 3 FARM E__] 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA C .. II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b lr&b 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AMWY CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bmininEbale D INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY ED CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE R WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4-T-4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ eor m Indlaale O 1 SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE E-1 4 SURETY BOND 0 5 LETrEROFCREDR O S EXEMPTION 0 W 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.O 11.[:] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PR INTED B S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY f� COUNTY x / JURISDICTION x FACILITY u 'IpF7r'IT—%�E�I LOCATION CODE -OPTIONAL CENSUS TCT:1 -Crj/ONAL SUPVISOR-DISTRICT DO E -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UN SS IS A CHANGE O E INFORMATION ONL FORM A(5-91) F