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Pw � �R h � xR STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL ARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORT 1 9 1 ENVIRONMENTAL �IfOPN', COMPLETE THIS FORM FOR EACH FACILITY/SITE PERMIT/ FIRVICE, MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION F] 7 PERMANENTLY CLOSED SITE ONE ITEM Ej 2 INTERIM PERMIT F__1 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ir4�1 r> 1 r ADDRESS NEAREST CROSS STREET PARCEL# PTK NAL) W t Z CITY NAME v :STATE ZIP CODE SITE PHONE#WITH AREA CODE (i 'f L toyI/ BOX TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS lle� 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN #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 D YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) . o NIGHTS: NAME(LAS ,FI S PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 4 ` '-'! c eI PHONE#VVITH AREA CODE Ii. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMECARE OF ADDRESS INFORMATION i MAILIN STREET ADDRESS ✓ box In indicate Q'INDIVIDUAL LOCAL-AGENCY STATE-AGENCY [ Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME F OWNER CARE OF ADDRESS INFORMATION 4 MAILIOR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY _Pn FN et�X 1490 CORPORATION = PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE 1't - IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -� I-1– 17TT7] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓ box b indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND D 5 LETTEROFCREDIT 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&SIGNATU E i APPLICANTS TIT DATE MONTWDAYNEAR , 1 Ld��jLd LOCAL AGENCY USE OWLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED FAT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A-5