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• • noon e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD w ao UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA n� P ryy ,4�1 COMPLETE THIS FORM FOR EAC ACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 8V I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA O R FACILITYNAM E p c `L NAME OF OPERATOR �aGL /l/�D �� PARCELI(OPTpNAII ADDRESS NEA TORO S REET CITY NAME STATE ZIP COD TE PHONE%WITH AREA CODE A G b J\ 3 ✓ BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY O COUNTY AGENCY D STATE AGENCY D FEDERAL-AGENCY TOINDICATE DISTRICTS TYPE OF BUSINESS ❑ ( GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION #Of TANNS AT SITE E.P.A. I.D.it(optimal) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER ORTRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE It WITH AREAQnr II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION div G N ✓ box bindle INDIVIDUAL LOCAL-AGENCY l� STATE-AGENCY MAILING OR STREET ADDRESS O //// L PoRATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY J STATE ZIP CODE HONE#WITH AREA CODE CITY P2 L e-7 z- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓[�� R,box(b liMkate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY xl/l S . !:!F -L`TaL�� S'7' PORATON PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE HONE w5;:;CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. TY(TK) HQ F41 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMkale i SELF-INSURED =2 GUARANTEE 3 INSURANCE L_I 4 SURETYBONC 5 LETTER OF CREDIT =6 EXEMPTION 93 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or II is checked. CHECK ONE 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 APPLICANTS NAME(PR IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# dAAe ) I ( LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL p-7. 7— L7 RZ p?-- 171-31 :W Z� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A5