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• 0 BOJe e 4 STATE OF CALIFORNIA J . / STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EAC CILIrYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T FERMANE LV CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5�- I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D AOR FACILITY NAME NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA �/✓—I(O —r - `rte ✓ BOX TO INDICATECORPORATION Q INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY O FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION n � ❑ 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 02- CA' .�-.1ip,q�e/131E EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) O .,l Pjl7j"9T— I-71� :17 IZr-4-1 PHnNFZ17-1 NIGHTS: NAME(LAST,FIRST) WITH NPOECTSL RS eizzq �Z2—�a�i72v; ' r COOP- 11. PROPPERTY OWNER INFORMATION-(MUST BE COMPLETED N'AM,,E11�^^ CARE OF ADDRESS INFORMATION MAILING OR`ST,REETADDRESS ✓bo bin6 W INDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY 911 W, 1 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE L..c� Inti Cloth, III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION G� I MAILING OR STREET ADDRESS _INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP Q COUNTY AGENCY (] 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 F4-F4]-jO O o IC7 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECO ED)—IDENTIFY THEMETHOD(S) USED ✓ box b Indicate O 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE O A SURETY BOND O 5 LETTEROFCREDIT =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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ 11.10/ III.❑ T141S FORM HAS BEEN COMPLETED UNDER P TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S AMS r E(PRINTEDIII SIG^U NAS) APPLICANTS TITLE DATE MONTWDAYNEAR tzo I T T+ 10-LO-9L LOCAL A EN Y USE ONLY 1 COUNTY# JURISDICTION# FACILITY# ® Idol 117 LOCATION CODE -D TIONAL CENSUS TRACT# -OPTIONAL SUPVISOR- I TRC CODE OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF S INFORMATION ONL FORM A(5-91) //Y� FOP