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6STA7E Of CALIFORNIA Suae • STATE WATER RESOURCES CONTROL BOARD Y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�'� � "e / J ''o I . � o' COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE O� I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY N/ /' �'+A�MEE NAME OF OPERATOR ADDRESS I NEAREST CROSS STREET PARCEL#(OPTIONAL) a 5 CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE cc` CA 2d - �3- aIs / I/ BOX TO INDICATECORPORATION O INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY [] COUNTY AGENCY O STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.A(optimal)RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER 0R TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH APPA 7,1111P NIGHTS: NAIME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) A WITH APPA r'nnp II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME - CARE OF ADORE SS INFORMATION f Gam. MAILING OR STREET ADDRESS ' ✓Det blMkate =1 INDIVIDUAL O LOCALAGENCY STATE AGENCY P,o. 3 `5 Ox '' CORPORATION = PARTNERSHIP Q COUMKAGENCY FEDERAL-AGENCY Cltt NAME STATEZIP CODE PHONE A WITH AREA CODE OYs< 5rn Y>< III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION /n/� Ado MAILING OR STREET ADDRESS ✓ Oat*'We ve O INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY C3 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 F4-5-1- 3 7 V. PETROLEUM UST FINANCIA ESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ la:nirdkate I SELFINSURED 0 2 GUARANTEE CI 3 INSURANCE A SURE N BOND O 5 LETTER OF CREDIT O 5 EXEMPTION O W OTHER 71 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 NAM E(PR INTED&SIGNATURF) APPLICANTS TITLE DATE MONTWOAY/YEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION# Y (J I FACILITY# 39 = i�� Iso LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL a 3 8v 3 a4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIOI FORM A(5-91)