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• • a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Gl I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NA NAME OF OPERATOR ADDRESS � � NEAREST CROSS STREET PARCEL 0(OPTIONAL) CITY NAME STATE ZIPCODE / ITE PHONE#WITH AREA CODE A7P CA v sox TOINOIIC TE CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY M FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / ❑ RESERVATDION #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM ❑ 4 PROCESSOR Le 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) 0;151�e5; ' 6"� 5601ST,FIRST) - W4% PHONE I WITH AREA rnDP NIGHTS: NAME(LAPHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS {� ✓ bo[bind&au INDIVIDUAL � LOCALAGENCY INSTATE-AGENCY S Q CORPORATION = PARTNERSHIP Q COUNTY-AGENCY E�] FEDERAL-AGENCY CITY NAME •` GTATX ZIC'ODE -� P}iONE# ITZC'CODE�� Ill.. TANK OWNER INFORMATION-(MUST BE COMPLETED) `r,r NAME OF OWNER CARE OF ADDRESS INFORMATION /w__//16+ 4/46j� MAILING OR STREET ADDRESS /J� �,/�- A /-� ✓ boa blrAkate D INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY Q S, /�!/Yi/`T7/rte 5/ 0 CORPORATION [-I PARTNERSHIP COUNTYAGENCY FEDERAL AGENCY CITU NAM Sz E ZIP CODE HONE 1LWITH AREA CODE lio1�� •�ifL(i/c, .Gv.,`�',lJ\ 7� o� �lyb/ IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ buiomdicale 0 1 SELF-INSURED 2 GUARANTEE a 3 INSURANCE A SUREtt BOND F=1 5 LETTER OF CREDIT D 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Iorllischecked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGILTLYAL_- ETTI s c19 LOCgTION CODE OPTIONAL CENSUS TRAC # -OPTIONAL SUZP1(70OR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATIONNL FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) F 0033A5 i