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�a STATE OF CALIFORNIA �^ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,n ! j y> . COMPLETE THIS FORM FOR EACH FACILITY/SlTE 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F _ ONE IT 2 INTERIM PERMIT O 4 AMENDED PERMIT re6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME I NAME OF OPERATOR e - ^ NEAREST CROSS STREET PARCEL#(OPTIONAL) ADDRESS `J5zo s. w >,Cti CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE e�c�.-� CA .52os ✓ Pox CORPORATION Q INDIVIDUAL PMTNEfl3HIP LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY TO INDICATE DISTRICTS TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION IF INDIAN MOF TANKS AT SITE E.P.A. I.D.#(optimal) 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) /gOYI -(133-3�3 EaersmIS er kepi .20 - 533-1300leer"# IPHONE NIGHTS: NAME(LAS .FIRSTj PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AR II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMEy - CARE OF ADDRESS INFORMATION I c S s n c N C'ar/ MAILING OR STFIEAETyADD SS ✓ box bindmale � INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY i O• 0 /. / /6�0(� 0 CORPORATION O PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY CITU NAME V STATE ZIP CODE PHONE M WITH AREA CODE Roe Are verb Ark Kovsas b 2/l -3323 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION (ZS MAILING OR STREET ADDRESS ✓ box bindIcate O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY I�CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONES WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - a y S V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ box mindicalb 1 SELF-INSURED =1 2 GUARANTEE 0 INSURANCE Q 4 SURETY BOND O 5 LETrER OF CREDIT l=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 Ills ghecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 it.v III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPUCANT'SNAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# a 6 1/ It IY��otts LOCATION COD€-OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR--DICT CODE -OPTIONA� 9z c THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYFORD A 5 FORM A(5-91)