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esoo. e STATE OF CALIFORNIA W coy9 STATE WATER RESOURCES CONTROL BOARD n_ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A i . COMPLETE THIS FORM FOR EACH FACILrrYISITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM O 2 INTERIM PERMIT F__1 4 AMENDED PERMIT 0 It TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY AME , NAME OF OPERATOR 0 5 r ' �i4/cAG %.rmfq •� ADDRESS NEAREST CROSS E ST PARCEL#(OPTIONAL) con s'�e/ &4 '[TY NAME r D STATG`EA ZIP COD I SITE PHONE`WITH AREA CODE TO INDICATE O CORPORATION IVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTYAGENCY STATE-AGENCY [71FEDERAL-AGENCY DISTRITYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.4(optimal) RESERVATION 3 FARM Q 4 PROCESSOR rHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) /J PHONE#WITH AREA COIDAYS:,NAME(LAST,FIRST) f li nn Lo• L , S -3 /V NIGHTS: NAME(LAST,FIRST) -PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA 1OQP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate E:1 INDIVIDUAL (1 LOCAL-AGENCY STATE-AGENCY 0 CORPORATION = PARTNERSHIP = COUNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER �__ CARE OF ADDRESS INFORMATION ;, 1, S / MAILING OR STREET ADDRESS ✓ boxbINIcale 0 INDIVIDUAL 0 LOCAL-AIIENCY 0 STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD-OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 74F4 - -11 1 13 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box birhicale 0 1 SELF INSURED [-12 GUARANTEE 3 INSURANCE 0 d SURETY BOND 5 LETTEROFCREDIT I1 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.F2 IIL= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PH INTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY C�OUNTT.YY# JURISDICTION# FACILITY It 7-y*/H /O d5l LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTI ODE -OPTIONAL 3 bk i G� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(5-91) FOfl0073A