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STATE OF CALIFORNIA = � �r�j� ,�Q.p� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA P COMPLETE THIS FORM FOR EA FACILITYISITE ❑ 1 NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED STE MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) ^ NAME O�P I TOR D gil� NIS VG' /j NEAR ST CROSS ST ET PARCEL#(OPTIONAL) ADD S 2 ..JCS STATE ZIP C E SITE PHONE#WITH AREA CODE CITY IN C� CA T NDIICCATE O CORPORATION INDIVIDUAL O PARTNERSHIP LS RICTGENCY Q COUNTY AGENCY I� STATE-AGENCY 0 FEDEML-AGENCY ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optbnap TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION r ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRU ST LAN DS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COOS DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED DA AD* ItIFORMAT N yr n NAME S box b Intliwte INDIVIDUAL l� LOCAL AGENCY O STATE AGENCY 7E MAILINGO S E DD ES$ ✓� '/Do�� /IS vL. / / L_]CORPORATION PARTNERSHIP 0 COUNTY-AGENCY LD FEDERAL-AGENCY STAT-, _ ZIP DE PHONE#WITH AREA C ODE CITU NA `/—I6r1 Z// III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME OF OWNER ✓ box b Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY []STATE AGENCY MAILING OR STREET ADORESS CORPORATION L-1 PARTNERSHIP = COUNTY AGENCY FEDERAL-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE CITY NAME IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO L4 4]-[p V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED [] 1 SELF INSURED 0 UA ANI Q 7INSURANCE O A SURETY BOND ✓ box to indicate EXEMPTION 0#U OTHER O 5 LETTER OF CREDIT 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: 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAVP/EAR LOCAL AGENCY USEONLY G U COUNTY# JURISDICTION# FACILITY IN LOCATION CODE -OPTIONAL _ I I-- � — - it NA� ,CENSUS TRACT# OP TION SUPVISOR IS IC Qlazi�� 23 �a i g � THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033AR6 0 X01ky7y