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eoXe STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD p UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A C�IiXOXXn COMPLETE THIS FORM FOR EACH FACILrrYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT d 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR WPrAlers S a e Oertito- ADDRESS NEARESTC OSS STREET PARCEL#(OPTIONAL) -V 62.-50 6.AdbV CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE gh-AW CA1� BOX 9S2o6 TOINOIIC TE O CORPORATION 0 INDIVIDUAL (]PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS E:] I GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(opfimap 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 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) PHONE#WITH AREA ronp Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION Same ds ,1 MAILING OR STREET ADDRESS ✓boxbinEicate OINDIVIDUAL (_1 LOCAL-AGENCY 0 STATE AGENCY 0 CORPORATION (] PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bon 0 rdicale [71 INDIVIDUAL LOCAL AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP [�j COUNTY-AGENCY Il 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 4141- aI q 19-16-FI-1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box 0 Wicale 1 SELF-INSURED [1:12 GUARANTEE E-1 3 INSURANCE 0 4 SURETY aOND O 5 LETTER OF CREDIT ❑96 EXEMPTION O 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. II.❑ 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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYYEAR LOCAL AGENCY USE ONLY COU(NTTYY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ?3, W 3415:— J 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 \