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STATE OF CALIFORNIA ,oma• <�` STATE WATER RESOURCES CONTROL BOARD • �y„ �'o O / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y� COMPLETE THIS FORM FOR EACHFACILrTYISITE MARK ONLY ❑ I New PERMIT ❑ 7 RENEWAL PERMIT [tj 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED ONE REM ❑ 2 INTERIM PERMIT a A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILI V N QAMEI O y I D I/ 2 G NAME OF OPERATOR ADDRESS YV Lim 7 �D V NEARS Si CROSS STREET 5� PARCEL I JOF IONAQ CITY NAME STATE/1•✓_✓ LP CODESITE PHONE i WITH A EA CODE T CA `l 3 7 L GCaS TOINOICAM Q COR -ART! LOCAL-AGENCY COUNTY-AGENCY STATE AGENCY FEDEPALAGENCY PORATIONDQ DISTTnCTS TYPE OF 3USINESS I GAS STATION �i 2 DISTRIBUTOR J IRF NA7IOIAN a OF TANK AT SITE E.P.A. L D.A(OWH Wi ❑ RESEVCN C O FARM A PROCESSOR ❑ 5 OTHER pR TRUST LANDS _ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional JAYS: NAME(L,AST.FIRS PHONE 1 WITH AREA CODE DAYS: NAME(LAST.FI ST) NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME tLAST.FIRST) --C'49'WITH AREA C009 II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAIL.NG OR STREET ADDRESS I J O.ow IQ INDIVIDUAL Q LOCAL AGENCY LJ STATE-AGENCY Q CORPORATION Q PARTNERSNP Q COUNTY#GENCY Q FEDERALAGEEWY CITY NAME I STATE ZIP CODE PHONE•WITH AREA CODE Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF CWNER CARE OF ADORESS INFORMATION MAILING OR STREET ADDRESS J ooAuuacaY Q INONOUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERS14P Q COUNrYAGENCY Q FEOEMLMGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -1010 101 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED J Om erafeaM Q I SELFJNSUREO Q i GUARANTEE Q F NSURANCE Q A A)NETY 20x0 0 5 LmEROFCRE(xT Q e MMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ It.❑ IIL❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME(PRINTED a SIGNATURE) APPLr ANnS TITLE DATE MONTWOA EAR l� LOCAL AGENCY USE ONLY Gr/ COUNTY tII JURISDICTION F FACILITY 1 I /V/01'/37 FTT� 2= LOCATION CODE -OPTIONAL (CENSUS TRACT I •OPTIONAL I SUPVISOR•01 RICT CAGE -OPTIONAL Z Y- L THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE WFORMATION ONLY. FORMA(i91) FGROGLIA-5