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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA o COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE QZi I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OB 0 FAC ITYNAME NAME OF OPERA OR chiEA1,R To�v t /r1�i✓/-�1a T 1J oNRDaN NEAREST CR0555 �� PMCELI(OPf10NAt) ADORE S �J� / n --CITY NAME �O STATEA ZIP CODE SIT�PHONE# TFi AREA CODE / TOO/ BOXINDICATE 0 CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY STATE-AGENCY Q FEOEML-AGENCY DISTRICTS TYPE OF BUSINESS �AS STATION 2 DISTRIBUTOR l❑ -/ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.#(opfionap RESERVATION Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LAN DS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DA"�//NAMWA,1IRL8 G 11J )DIV ITH ACODE GAYS: NAME(LAST.FIRST) O NIG T ' NAME(LA$T,FI S �� PHONE N WITH AREADCO'D NIGHTS: NAME(LAST,FIRST) 1 -ffj II. PROPERTY OWNER INFORMATION MUST BE COMPLETED CARE OF ADDRESS INFORMATION 7MAMLE �� ,/� GO-STREET ADDRESS f• ✓ bexbintlkale 1 INDIVIDUAL 0LOCAL-AGENCY 0STATE-AGENCY CORPORATION = PARTNERSHIP E:] COUNTY-AGENCY lj FEDERAL-AGENCY STATE ZIP CODE PHONE at WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OW NER CAPE OF ADDRESS INFORMATION /4/z- -WAILINGOR STREET ADDRESS ✓ box bindicate = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY CORPORATION = PARTNERSHIP Q COUNTY-AGENCY [_j FEDERAL-AGENCY - -EITU 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 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicale = 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE O 4 SURETYBOND O 5 LETTER OF CREDIT O B EXEMPTION O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or[I is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I it.[1] III.❑ THIS FORM HAS BEEN59M9TED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT IF APP T'S NAME INT (GNAT APPLICANTS TITLE DATE MONTH/DAYIVEAR il.PTd.� ,P w•�/�e v� / 93 L AGENCY USE ONLY COUNTY# JURISDICTION K FACILITY# 0 aaffl-IF_ ff LOCATION CODE .OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION FOR0033A 5 , I FORMA(5-91)