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coua STATE OF CALIFORNIA <, i STATE WATER RESOURCES CONTROL BOARD � $ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT [j q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) AOR FACILITY NAME NAME OF OPERATOR 0140m FcNe ti{✓�� T ADDRESS NEAREST CROSS STREET PARCELx(OPrgNAL) zoo E. Nkrrr CITYNAME73- Oyo -',fig-'7 STATE ZI jP CODE SITE PHONE M WITH AREA CODE v BOX ' OC CA TOO INDICATE 0 CORPORATION 0 INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY DISTRICTS 0 COUNTYAGENCY O 3TATE.AGENCY 0 FEDERALAGENCY TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x(optimal) O 3 FARM O q PROCESSOR 5 OTHER RESERVATION O OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) S �S— NIGHTS: NAME(LAS ,FIRST) PHO x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) _ II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION 13W If MAILING OR STREET ADDRE ✓ boxmirmmate I= INDIVIDUAL 0 LGCALAGENCY D STATE-AGENCY D X 30731 0 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE x WITH AREA CODE oc k4vtj C III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N,AMEOF OWNER _ CARE OF,ADDRESS INFORMATION AILING OR STREET ADDRESS »s /�� -S R box mindiwle j INDI DUAL l� LOCAL-AGENCYiTATE E "�ax CORPORATION I�FEDERAL-AGENCY CITY NAME D PARTNERSHIP 0 COUNTY 0 FEDEgALdGENCY --top � STATE ZIP CODE PHONE x WITH AREA CODE C e'4 szo IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4-[4—]- O 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM THOD(S) USED ✓ box mintlmale l� 1 SELF INSURED L—A2 GUARANTEE Q INSURANCE D 5 LETrEROFCREDR 6 EXEMPTION O A SUflE VBOND 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or IIchecked. 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION if FACILITY# ® 2 Z G d-Co id 2 p LOCATIONCODE -OPTIONAL CENSUS TRACTx -OPTIONAL SUPVISOR-DISTRICT CODE917 1 -OPTIONAL 21z. 3A19- THIS FORM MUST BE ACCOMPANIED BY.Al LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION O FORM A(5-91) NLY. FOR0097A3