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�isouN a o STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD if= /j UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A / ryi C•l�n4N Y•n COMPLETE THIS FORM FOR EACH fACILITYISITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OaA Q9.FACILI 'NAME / / C/// /y �-r+ ^ NA E OP RATORsh�ma� ADORE l/X✓� ./YV NEA TCROSS STREET PARCEL#(OPTIONAL) � 5 . 1 ax I CITYNAME STATE ZIP COgfi SITE P NE a WITH AREA CODE CA C/7 p91-111 ✓ Box TO INDICATE F]CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNrY.AGEWY E3 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR D / IF INDIAN RESERVATION #OF TANIS�AT SITE E.P.A. I.D.x f0plimal) O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS TAD EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE,WITW APPA rnnp NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box biMkale E-1 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION E-1 PARTNERSHIP E3 COUNTY-AGENCY fl FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box biMkale OINDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 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 3 Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box biMkale O 1 SELF INSURED E::]YGUARAMEE Q 3INSURANCE [:j 4 SURETY BOND O 5 LETTERCFCREOR Ne6 EXEMPTION Q 93 OTHER 771 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: L D ]I.O III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY ��yy COUNTY# 41k JURISDICTION# FACILITY# LOCATION COQE/OPTIONAL CENSUS T?Py OP-jJ6L SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(5-91) 1C) -q -C� 1