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' peyoun ; o0 STATE OF CALIFORNIA P I ^ STATE WATER RESOURCES CONTROL BOARD, UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A e De CXlIf4XYX COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT � CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE M I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACIU�ME Sys NAME OF OPE ,TOR/ (/ x?C S rV ADDRESS f / NEAREST CROSS STREET PARCEL If(OPTIONAL) 7D i.✓ SCnvi T= CITU NAME STATE 21P ODE TE PHON #WITH AREA CODE ,r c4 CA z g5g,y/3 I ✓ BOX TO INDICATE Z5—CORPORATION Q INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY I� COUNTY-AGENCY 0 STATEAGENCY I� FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR E?-6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) I PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) �V1CQ � �lx V —r� 8-5g-- `_Y13 PHONF#WITH AREA COT: _ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA Con" IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME , /'C-S CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS// ✓ box blMicate = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY ( Z U O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL AGENCY CITU NAME STA E ZIP CODE PHONE#WITH AREA CODE L }I�rc,P cil � S33p 20 �SSSr—Y/3� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION C Lt S —MAILING GOR STREET ADDRESS ✓ box b Indicate INDIVIDUAL O LOCALAGENCY 0 STATE-AGENCY [=CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY I= 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 4 4 - 3 z z 2 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box biMlcate I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE Q d SURETY BOND E 5 LETrER OF CREDIT 0 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# TUi-`B LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 26 f_319—cj2 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) FOROIXi3A3