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• � peeoua ea STATE OF CALIFORNIA +, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITWSITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTL CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z 5 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FAC NAME NAME OF OPERATOR ClawsIndA ADDRESS '7 �CpO' NEAREST CROSS STREET PARCEL%IOPrIONALI CITU NAMSTATE 21P CODE SITE PHONE%WITH AREA CODE CA ✓ BOX TO INDICATE - CORPORATION E__1 INDIVIDUAL 0 PARTNERSHIP L-1 LOCAL-AGENCY COUNTY-AGENCY STATEAGENCY E71 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ */ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.%(oplianap RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST.FIRST) PHnNP NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME 11)0L fjp,�� RESSIrvMATION -m-1L derp) l4 Mo MAILIN613 STREET ADDRESS cGJ✓box biMkale I DIVIDUAL O LOCAL-AGENCY I� STATE-AGENCY lY2- bneoln �' OCORPORATION VARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY CITUNJ` Clk4� 0 STATE ZIP COO�� HONE%WITH AREA CODE zoo III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l/J' '� �7) Q/ NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS v box b indicate Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY I= 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 F41 4 31Z 2-2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicate I] I SELF-INSURED �GUARANTEE E�:] 3 INSURANCE L�] 4 SURETY BOND L-1 5 LETrEROFCREDIT LV 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 i hecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.le ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# F CILI Y# Lsv nsrh 61101 LOCATION CC©E -OPTIONAL CENSUS TRACT# 'OPj1pfJPl Sl1PVISOR-DISTRICT CODE -OPT/ 73",96 4J 3 tC/a(6 32 THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION f FORM A(5-91)