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` • � '`6pU11 STATEOFCAUFORNIA • .r i STATE WATER RESOURCES CONTROL BOARD i g UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILrrY/SITE MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE I. FACILITY/SITE INF RMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR oo� -z-70004GIiOe� DDRESS NEAREST CROSS STREET PARCEU IOPrKINAU S'JGi r c� - CITY NAME �� STATE ZIP CODE TE PHO E s WITH AREA CODE r/rrr caI/ BOX Z�� TO INDICATE O CORPORATION Q INDIVIDUAL [-I PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY AGENCY' O STATE AGENCY' 'tt owner d UST Is a public agency, S DISTRICTS' FEDEML#GENCV' P 8 ncl'.corrplde the lollowin :harre of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS ED 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN MOF TANKS DIT SITE E.P.A. I.D.s(Optimal) 3 FARM 0 4 PROCESSOR �5 OTHER OORRRUSTVLANON r EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCYCONTACT PERSON (SECONDARY)•optional DAYS: AME(LAST,FI ST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIflST) CO�` PHONE S WITH AREA CODE NIGHNAME .(LAST,NAMAST,FIRST) PHONIE S WITH AREA CODE? NIGHTS: NAME(LAST,FIRST) 3GF-7 (, PHONE 4 WITH AREA CODE II. PROPERTY OWNE INFORMATION- MUST BE COMPLETED NAME /ryt� SAO G�� CgRE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bind", O INDIVIDUAL ED/00 S-. SG' L �j ORPORARON PARTNERSHIP LOCAL AGENCY STATE-AGENCY CITY NAME O COUNTY#GENCY O FFDEMUAGENCY STA Zip pCDOOE NE,s rITH AREA CODE III. TANK OWNER INFRMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION oDr ® G• MAILING OR STREET ADDRESS ✓ box--- bidicale =1 INDIVIDUAL LOCAL-AGENCY E] STATE-AGENCY RPORATION O PARTNERSHIP Q GOUNrY-AGENCY O CI NAME STAT ZIP CODE FEDERAL odd 95Z�o PHONES ITN gREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91/6)322-9669 if questions arise. g TY(TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box binEbLs E-1t SELF INSURED i GUARANTEE O 3 INSURANCE O 5 LETTEA OF CREDIT a EXEMPTION O 99 OTHER E-1 A SURE Y BOND VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E II.r—] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAVfVEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTK)N IF FACILITY t /5 LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL 9� Rte-pISTRN:T 665E_-—opriomL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION NL FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 FORDMIAA7