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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iy - UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACT E MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ' 114 r, w CA 9S33( aD9 643 -7/dY TO DICCATE O CORPORATION M INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY ED COUNTYAGENCY SrATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ ( STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#*11mal) RESERVATION FY'3�FARM O A PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ,Elancy� Carr J01P - -f- 7/.Jo( — NIGHTS: NAME(LAST.FIRST) t PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE IL PROPERTY OWNER INFORMATIONMUST BE COMPLETED NAME - CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa bindkah 0INDIVIDUAL LOCAL-AGENCY (:1 STATEAGENCY (]CORPORATION O PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxblMkaa Q INDIVIDUAL 0 LOCAL-AGENCY a STATE-AGENCY 0 CORPORATION PARTNERSHIP =COUNTY-AGENCYQ FEDERALAGENCY 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 F41 4 013 1 a I a a 1 (. V. PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa bukkab 1 SELFINSURED Q 2 GUARANTEE 0 ] INSURANCE A SURETY BOND D 5 LEITER OFCREDT Q 6 EYEMPnON 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II'Admecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LII.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY Ix JURISDICTION It FACILITY It EE 0 / LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 32 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) FORCO]]A5 *PIK 5 1- 8Z 0 ��