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�� . . v. 5OUR e a STATE OF CALIFORNIA Pe co STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR E---Ayy�CH FACILITY/SITE MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR L)(J CD ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE o p,11 CA W-1-3-n133-11 ✓ BOX TO INDICATE D CORPORATION INDIVIDUAL 0 PARTNERSHIP E:J LOCAL-AGENCY COUNTY-AGENCY 0 SLATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION L 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR = 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) Ik NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) tiM/aYDr3. Lrvtr, ` PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION -14, P, r v.G T,5 4 Vii- 1-,"r1 O 1�la i, MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 'afj ZG1 E- 1111 Yom- aT a�,�/ ORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR ST3EET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY r_-, �.}r/ CORPORATION PARTNERSHIP 0 COUNTY-AGENCY OFEDERAL-AGENCY CITY 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 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION 99 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. 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 MONTH/DAY/YEAR Lot" LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# �� .Fff 2 1 1p Kau Lai4P/0-1 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 ONLY. FORM A(5-91) FOR0033A-5 a