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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY NEW PERMIT u 3 RENEWAL PERMIT 77 5 CHANGE OF INFORMATION I 7 7 PERMANEN OSE ONE ITEM 2 INTERIM PERMIT C) 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE � 1. FACILITYISITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 1, / DBA OR FACILITY NAMEZ� NAME OF OPERATOR MAILING OR STREET ADDRESS ✓ box to, indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) STATE ZIP CODE PHONE # WITH AREA CODE CITY NAME �� I STATE ZIP CODE G�//�7JS2. SITE PHONE # WITH AREA CODE CA ✓ BOX TO INDICAT ELORPORATION Q INDIVIDU Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR # OF TANKS AT SITE E.P.A. I. D. # (optional) �50THEFI RESERVATDION 3 FARM U 4 PROCESSOR OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional If PRO PFRTY OWNER INFORMATION -(MUST BE COMPLETED) NAME ^ I .� � CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to, indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q 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 STREET ADDRESS ✓ box toindicate � —vINDIVIDUAL LCCAI•AGENCY STATE -AGENCY 5 /:2 S7 CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE /V U f V V I I G-1 - IV. BOARD OF EQUALIZATION UST STORAGE FEE A COUNT NUMBER - Call (916) 323-9555 if questions e. TY (TK) HQ 4:[447! -F—I V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE ❑ 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT iQ 6 EXEMPTION C] 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. = III. II 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 IDAYNFAR — -z-/ LOCAL AGENCY USE ONLY w� . ` y COUNTY # JURISDICTION # FACILITY # LOCATI CODE - OPTIONAL NSUS SUPVISOR - DISTRICT CODE - bP L �Z7 v Z— THIS FORMA MUST BE ACCOMPANIED BY AT LEAST H I OR MORE PERMIT APPLICATION . FORM B. UNLESSTHISIS A CHANGE OF SITE INFORMATION ONLY. FORM A (12 91) RLE THIS FORM WITH THE LOCAL LGENCY dPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS OR 33 R6�� 1�