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STATE OF CALIFORNIA .�a.•^V~ `. STATE WATER RESOURCES CONTROL BOARD ;•! '� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e COMPLETE THIS FORM FOR EACH.F4611.1rYISITE MARK ONLY F71 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION EDT PE NENTLY E ONE IT ❑ 2 INTERIM PERMIT a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 6e/ Md ADDRESS 1 © 5Y NEAREST OO-rWSTREET t5 ! PMCELA(OPTIONAy CITY NAME STATE/,(V( F-ZIP CODE SITE PHONE A WITH AREA CODE CAv Box 5 TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP EhLOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ L GAS STATION ❑ 2 DISTRIBUTORf� q/ IF INDIIAN ON #OF TANKS AT SITE E.P.A. I.D.#(optimal) Q 3 FARM Q a PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST,FIRS PHONE#WITH AREA COOS DAYS: NA (LAS TF T) �� -Zf yy1�' Day to 2�1r e LU Od -/ NIGHTS: NAME(LAST,FIRST) PH eA IA E A WITH AREA CODE NIGHTS: NAME(LAST.Fpr) PHONEs WITH ARE 4 Cot II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boa At MKIC314 Q INDIVIDUAL C:I LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ ma 0INKal# INDIVIDUAL Q Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE ME OD(S) USED ✓ boa biMeate Q 1 SELF-INSURED Q 2 GUARANTEE Q INSURANCE Q a SURETY EONO Q 5 LETTEROFCREDIT Q 6 EXEMPTION 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. CHE 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(PRINTED 6 SIGNATURE) APPLICANTS TITLE GATE MONTFODAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# - m v 010 s LOCATION CODE -OPTIONAL DEN SUS TRACT# •OPTIO(JAL SUPVISOR•DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM 9,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOROOAA 5 is ALI `'