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P n STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �4npn Nor COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORM ON&ADDRESS-(MUST BE COMPLETED)of ERATOR , Lr De ILI NAME AO AA I 1/A NE STC 1SS�STREET PARCEL#(OPTIONAL) ADDRESS ��- Ni le Rd1 �KIt T�ASEA STATE Z11 CODE ITE PHONE# 70pLACA S /bUAu400L GpD LL FEDERAL T,/ BOX TE D CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY O FEOEPAL'AGENCV DISTRICTS TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Wtimrap RESERVATION f I�,eo0Qi6-7 1 ❑ 3 FARM ❑ 4 PROCESSOR �] 5 OTHER OR TRUST LANDS 1 7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional YE(LAST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) 0 K 2dl kTS:?WPHONE 9 WITH AREA 7XIIII - NIGHTS: NAME&MT,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY�OWN �ORMATION- MUST BE COMPLETEDCARE OF ADDRESS INFORMATION NAM ✓ bor tlintlluu MAILING OR STR TADDRESS O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY .l O A� Q.Z CORPORATION � PARTNERSHIP I� COUNTY-AGENCY 0 FEDERAL AGENCY CI NAME (` J ST J�� ZIP 1 C� 7 AAO) #WITHAREA.7 r— I? III. TANK OWNER INFO TION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME F WNER Ca Gtn MAILI OR STREE OGRESS ✓ boxbintlbale INDIVIDUAL , :LOCAL-AGENCY O STATE-AGENCY Q CORPORATION O PARTNERSHIP = COUNTY-AGENCY Ej FEDERAL-AGENCY CITY ME V STx # IP Z �D i� HONE# IT AREr-: A— S 2^ LJ IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. TY(TK) HQ 4 4 -L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blikbak E-11 SELF-INSURED E-12 GUARANTEE S INSURANCE [_jC SURETY BOND 0 5 LETTEROFCREDIT [::]6 EXEMPTION 0 99 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. "7-HIS TING WHICH A4ADESSULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑AS BEEN COPENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT EpB PLICANI TIT E DATE M NTHID /NEAR LOCAL AGENCY USE ONL J COUNTY# JURISDICTION# FACILITY m O LOCATION CODE -OPTIONAL CEN SUS TRACT# -OPTIONAL 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 ONNLLYY. 5 FORM A(5-91) � � ��IIi�/� W