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STATE Of CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A vlo - y COMPLETE THIS FORM FOR EAC ACILITYwrE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE n ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �YS I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) «V// D6 RFACILITY E ¢ — 51 NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL##OPTIONAL) D W. XMjc CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE bcK CA Box TO INDICATE f1 CORPORATION O INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN •OFT S T SITE E.P.A. L 0.a(cptormiII O 3 FARM O A PROCESSOR ❑ 5 OTHER ORi RUSTVLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: NAME(LAST,FIRST) PHONE+WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME O CARE OF{IDDRESS INFOB�7w't MAILIN q/G]/�TREET KESS ✓ ImXto/�irak 14 Q�INDIVIDUAL V O LOU , iAGEHC CORPORATION PARTNERSHIP Q COUWTY-AGENCY FEDERAL-AGENCY LI IT NA STATE ZIP CODE PHONE a WITH AREA CODE L//�/'ly III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ W.0 mcm O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY Q CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ a Fs - 0 0 0 o V. PETROLEUM UST FINANCI 'RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED F: �¢blMcu. I SELFINSURED �2 GUARANTEE 9 INSURANCE CI A SURETY BOND F: 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or II is ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.Ee 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 MONTWDAYIYEAR LOCAL AGENCY USE ONLY n /y��/ COUNTY x Y JURISDICTION If FACILITY It J91 LIND e730 � 9 LOCATION CODE .O TIONAL CENSUS TRACT, .OPTIONAL SUPVISOR DISTRICT CODE .OPTIONAL / D 23. 15 ' V THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5.91) FORO61iA5 I