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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EA H /SITE MARK ONLY ] 1 NEW PERMIT O 3 RENEWAL PERMIT WWF5 CHANGE OF INFORMATION7 PERMANENT V CLOSED SITE ONE ITEM O 2 INTERIM PERMIT E_—] a AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 4EID D� V I Ac1G X12 ADDRESS J• �7 �e77 'f`U ,a . ' NE EST QRAeAOSS JqT EET PMCELRIOP ZONAL) CITU NAME n/T TI��,�-7 /Y.-lY STATE ZIPCODESITE PHONE*WITH AREA CODE/ ✓ BOX Pa CA Z�) l3! —1,49 TO INDICATE D CORPORATION INDIVIDUAL E]PARTNERSHIP O LOCAL-AGENCY F—I COUNTYAGENCY l:71 STATE-AGENCY M FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS TATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE FARM Q 0 O RESERVATION 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) j5;�CA! CZos) :1fd-617 NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINGORSTREET ADDRESS INDIVIDUAL�--. �'l,y�^ ✓boa binObale D INDIVIDUAL ED LOCAL-AGENCY I Z a-6 /V 7 �iP� '�/�� CORPORATON ED PARTNERSHIP STATE-AGENCY (] CWNTY#GENCV Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE '! /' 6 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER j CARE OF ADDRESS INFORMATION 24c— &r �8- Tib MAILING�OfR�STREET ADDRESS �y�� /�,� ✓ boa bin0icala INDIVIDUAL LOCAL-AGENCY STATE-AGENCY I2 M� CI Y NAME E-1 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY E=I FEDEML#GENCY y STvoC rv� STATE ZIP CODE PHONE#WITH AREA CODE 2zx90 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 METHOD(S) USED ✓ boz biMbala l___I 1 SELF INSURED 0 2 GUARANTEE O S INSURANCE D<SURET 5 LETTER OF CREDIT Y BOND l�6 EXEMPTION l� 9]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: 1.0 IL III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PA NTED B S IGNATU RE) APPLICANTS TITLE DATE MONTWDAV/YEAR LOCAL AGENCY USE ONLY COUUN�NTTYY# JURISDICTION# FACILITY# Iia-1 I O '� VSA 7_1 LOCATIONNA CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIOL �� 3. 1i2i '5 zv £! -' h 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORM TION ONLY. FORM A(5-91) FOR6633A5 \. o� 1s