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... `. STATE OFCATIFOTNA ,.�`• c`; STATE WATER RESOURCES CONTROL SWARD ' V UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FA /SITE `'l�•m1M�- MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERM OSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME NAME OF OPERATOR ADDRESS /,-/� NEAREST CROSS STREET PARCEL#(OPrIDNAIj CITY NAME /� STATE SITE P N s AR CODE CA /Q'v !/ BOXO CORPORATION INDIVIDUAL PARTNERSMP LOCALAGCY Q COUNTYAGECY' STATE-AGENCY' O FEDEPAL,BNCY' TOIN DISTRICTS' •I oxner of UST Is a public agency,complete the idloxM#:name of Supervisor of tlN6bn, ion,a off which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR = .1 IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#fgoaanae RESERVATION 0 3 FARM Q 4 PROCESSOR 540 ER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: IN ( ST,FjI RS EACODE DAYS' NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NA T.FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME 4 CARE OF ADDRESS INFORMATION Mo j Ie MAILING OR STREET ADDRESS ✓ O INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY I D I 3 CORPORATION O PARTNERSHIP 0 COUNTY#GENCV Q FEDERAL-AGENCY CITY NAME 9T ZIPPHONE#WIT H AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bYOkak INDIVIDUAL LOCAL-AGENCY STATE-AGENCY ED CORPORATION PARTNERSHIP COUNTY#GENCY FEDERALAGEWY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-f4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bm bYNkaM l� I SELF-INSURED ED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND f�5 LETTER OF CREDIT O 6 EXEMPTION 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11.0 III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNERS TITLE DATE MONYNEAR Z LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# OCATION CODE CENSUS TRACT# -OPTIONAL SUI-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. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS EOf1907UA7 FORMA(393)