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' Go veru(. U G Y7 '3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �eOe NDN COMPLETE THIS FORM FOR EAC CILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT DK5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORF CILITYNAME� NAMEOFOPERATOR ADDRESS NN x NEA STC SS TREET PARCEL#(OPTIONAL) CITY N MEJ / x - STATE ZIP LADE SITE PHON BOX TO INDICATE CA L11 WITH AREA CODE O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(optimal) RESERVATION 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST FIRST) PHONE#WITHAREACODE DAYS: NAME(LAST,FIRST) oma- e (abq) 4-7P– !S47;;t— PHONE A WITH AREA CnnF GHT NAME(LAST,FIRST) PHONE#WITH AREA DE NIGHTS: NAME(LAST,FIRST) If I PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME f}rc�i CARE OF ADDRESS INFORMATION MAILI GOR STRE ADDRESS _ �r1G / box birbicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY &V IVV 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY f9Ay1 STATE ZIO PHONE# ITH AREA CODE /{ —7 \J – V / III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERCARE OF ADDRESS INFORMATION S MAILING OR STREET ADDRESS ✓ WxbMicale INDIVIDUAL LOCAL-AGENCY STATEAGENCY L-1 CORPORATION PARTNERSHIP O COUNTY-AGENCY O 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 74F4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box blMbate O I SELF INSURED 712 GUARANTEE E:1 3 INSURANCE 0 A SURETY BOND 5 LETTER OF CREDIT O 6 EXEMPTION 99 OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE 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) APPLICANPS TITLE DATE MONTHUDAYNEAR LOCAL AGENCY USE ONLY — (Z • q S COUNTY�# JURISDICTION# FACILITY# LOCATION CODE -OPT/ONAL CENSUS TRACT# -OPT;ONAL SUPVISOR-DISTRICT COD - THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGEJEARE INFORMATION ONLY. FORM A(5-91) YID F��A�ry\