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• � viJUN : C` STATE OF CALIFORNIA 'o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A •; ,,, o, NJNY" COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ D RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA FAC ITY NA E NAMEOFOPERATOR �o�er L)Kon ADDR$ trf j_ N REST CRO TREET PMCEIe(OP(IONAU CITY {AMfj 'll"JJ. J STATE ZIP 1V/CVLyE�•r�•"o SITE PHONE WITH AREA CODE cb tJ.(c G. CA TO N, Box l�CORPORATION INDIVIDUAL O PARTNERSHIP �LOCAL-DISTRIGENCY 0 COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR TS ❑ RESERVATTION U11IAN x OF TA SITE E.P.A. 1.D.#(optional) O D FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) INITH AREA Coolx It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxWNk9 O INDIVIDUAL 0 LOCAL AGENCY 0 STATE AGENCY Q CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL AGENCY CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ W.0 iibkate 0 INDIVIDUAL 0 LOCAL AGENCY Q STATE-AGENCY O CORPORATION 0 PARTNERSHIP 0 COUNTWAGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. TY(TK),HQ F4-F4]- Q 3 2 Z to V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE MET OD(S) USED ✓b9x bliblaw 0 I SELF-INSURED Q 2 GUARANTEE a INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT O 5 EXEMPTION OV99 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: 1.❑ 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&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAA LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# /Iql ® ZIKok LOCATION CODETIONAL CENSUS TRACT# -OPTION SUPVISOR-DISTRICT CODE -OPTIONAL p-OP23. 0D 5 2 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY Y'AS FORM A(5-91) \