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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 FACILITYISITE MARK ONLY Q EW PERMIT F73 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PER T D SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE 2 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME n LJ NAMEOF OPERATOR ADDRESS l/✓`n/ /j NEARESTCRO STR(EL�-/� PARGEIa(OPfgNAy LI CITY NAME STATE ZIP CODE 07eSITE PHONE a WITH AREA CODE CA `9 v Box TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN s OF TANKS AT SITE E.P.A. L D.a(cp hral) RESERVATON Q G FARM Q 4 PROCESSOR Ct<OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) H II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bmblydi Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAGEKY Q FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ WX0 Wic" Q INDIVIDUAL Q LOCALAGENCY Q STATE AGENCY CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAG FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 V. PETROLEUM UST FINA IAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boc bineicate 1 SELRNSURED =12 GUARANTEE Q 7 INSURANCE O 4 SURETY BOND Q 5 LETTER OFCREDIT Q 9 EXEMPTION [399 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.❑ IL❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PR INTED A SIGNATURE) APPLICANTS TITLE DATE MONTWCAYNEAR q LOCAL AGENCY USE ONLY C�O[UNTN�TY# JURISDICTION K FACILITY Y LOCATION CODE -OPTIONAL ICEN US 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) FORMA 5