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g4gOVe P STATE OF CALIFORNIA ` STATE WATER RESOURCES CONTROL BOARDAl gig. UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED �SITE j ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ✓✓ DBAORF ILI NAME NAME OFOPERATOR a . Q�C ADORE057 I V zvn NEARES O PARCELp(OPFIONAL) O CITY NA STATEZIP CO SITE PHONE#WITH AREA CODE CA ✓ Box TOINDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP E�] LOCAL-AGENCY Q COUNTYAGENCY O STATE AGENCY D FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS O t GAS STATION O 2 DISTRIBUTOR O IF INDIAN In OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION = 3 FARM ❑ 4 PROCESSOR EV 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) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING SIRE ADDRESS '^ry/',� ✓ box bintlkate INDIVIDUAL O LOCAL-AGENCY STATE AGENCY ��j(y—(/✓ f I�CORPORATION PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY CITY NAME Cr_T o" STAT7J< _ ZIP CO 5 ` PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /V`�x //O NAME OF WNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS r r box 0Indicate O INDIVIDUAL E�j LOCAL-AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP = COUNTY-AGENCY FEDERALAGENCY 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 14141_ Vk J1GL V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box oinbicale 0 t SELF-INSURED UARAMEE l� 3 INSURANCE O 4 SURETY BOND D 5 LETTEROFCREDIT 6 EXEMPTION Ij 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. 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 COQ# A51C IURISDICTION# FACILrTV= D g/b 9 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTJQNAL -D SUPVIS TRI7 CODE -O ^ - / 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) FOR0033A5 x