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STATE OF CALIFORNIA +„ STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ' J COMPLETE THIS FORM FOR EAC5,nCILITYISITE MARK ONLY ❑ 1 NEW PERMIT 71 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS• (MUST BE COMPLETED) DBA OR FACILITY NAME NAME41USS 't OF OPERATOR ADDRE SNEAREST CR SS STREET PARCEL#(OPTIONAL) Q me lI wls CITY NAME STATE ZIP CODE O SITE PHONE#WITH AREA CODE TO INDICATE IM CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY El COUNTY AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ❑ RES/ IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(optigTal) 0 3 FARM Q 4 PROCESSOR EW11THER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,F ST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) Caoq - boaPHONE A WITH AREA MQF NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PWQNP 4 WITH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME /^V p- CARE OF ADDRESS INFORMATION PQ ipss l� MAILING OR STREET ADDRESS ✓ �a b'vAIAu INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY W, O CORPORATION I� PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME #dSTATE ZIP CODE 77777 HONE#WITH AREA CODE 0 III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ ma 0imi w O INDIVIDUAL LOCAL-AGENCY a STATE-AGENCY a CORPORATION PARTNERSHIP O COUNTY-AGENCY F-I FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)323-9555 if questions arise. TY(TK) HQ F4_74 - A a V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ boa bimkal# Q I SELF-INSURED Q 2 O ANTEE O 3 INSURANCE O A SURETYeOND I=5 LETTEROFCREIT EXEMPTION a 97 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.�-j 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 8 SIGNATURE) APPLICANTS TITLE DATE MON THIDAYNEAR ;;;; LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACIL T1JJ 2:7 0A1 LOCATION CODE -OPTIONAL CENSUSTRACT.-OPAL SUPVISOR-DISTRICT`CODE .OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.ATT�/((11LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �\ FORMA(5-91) / / MAY] FOR053A-5 � ��