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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILrTYISITE MARK ONLY 3 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR sha ADDR SS NEAR CROSS STREET PARCELN(OPTIONAU CITY NA ^� TVY ` STACA 'PCO 'R07 SITE PHONE%WITH AREA CODE I/ BOX TO INDJATE CORPORATION INDIVIDUAL E-1 PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE AGENCY (] FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR O -/ IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.%(optMNQ RESERVATION O 3 FARM O 4 PROCESSOR S OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON ( RIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHON WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE%7 AREA CODE NIGHTS: NAME(LAST.FIRST) PHQNP 8 WITH AREA CODE- 11. PROPERTY OWNER INFORMATION• MUST B OMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ Imbindb 0INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDEML-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE III. TANK OWNER INFORMATION:(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS bablmd m = INDIVIDUAL Q LOCAL-AGENCY STATE AGENCY CORPORATION 0 PARTNERSHIP COUNTYAGENCY FEDERAL AGENCY CITY NAME ATE 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 4 4 - D y 7 1p V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ WXWWM ab I= 1 sar INSURED I=2 G WEE L-1 3 INSURANCE 4 SURETY BOND L-1 5 LETTER OF CREDIT EMPTION I= N 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O 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) APPUCANTSTITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY —S:HA W V52, COUNTY% JURISDICTION% FACILITY It LOCATION CODE -OPTIONAL CENSUSTRACT% -OP PO 3 ^^ SUPVISOR-DISTf �L THIS FOMUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITEFO ATION Y. FORM A(5-91) )65e f3A5 93 TQ