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I, (Ivo C"')) STATE OFCALIFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A HCOMPLETE THIS FORM FOR EACN ACILRYISITE MARK ONLY F-] i NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE G I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITYN E ♦ NAME OF OPERATOR AA ewt-c� ADDRES9 NEAREST CROSS STREET PARCEL#(OPTIONAL) C NA E STATE 21P OOE 31 PHON #WITH AREA CODE .S CA o20 9 Box 3 — Q TOO INDICATE O CORPORATION L]O INDIVIDUAL �PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERALLGENCY ` DISTRICTS TYPE Of BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(AW") RESERVATION 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COD DAYS: NAME(LAST,FIRST) —IC-7 * PHONE A WITH AREA r=1 IhI PNIGHTS. N ME( .f T) OWNIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA COD� Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION InA MAILI GORST EET ADDRESS U ED INDIVIDUAL O LOCAL AGENCY 0 STATE�AGENCY 47 172 141�m� i D CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY �CITY NAME S TE ZIP CODE PHONE#WIT AREA CODE III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION cz'C MAILING O TREET ADDRESS ✓ boablMbale INDIVIDUAL O LOCAL-AGENCY O STATEAGENCY CORPORATION PARTNERSHIP O COURrY-AGENCY 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 F4-T-41- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ boa blMit Wa I SELF INSURED 0 2 GUARANTEE (]3 INSURANCE (]4 SURETY BOND D 5 LETTEROFCREDIT 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(P R INTED&SIGNATU RE) APPLICANTS TITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY A4 CODU�NTTYY# JURISDICTION# FAC - 3 Y LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPV130R-DISTRICT CODE - 3 a: ' a D. - THIS FOR Mr MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONV. FORM A(5-91) F 30A5 �A ��