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u ti STATE OFCAUFORMA �• �' STATE WATER RESOURCES CONTROL BOARD W m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 e '. rte.; o' �nt,nOYY`n COMPLETE THIS FORM FOR EACH F rTYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR on Lo k/P.,/y�?__ ADDRESS / NEAREST CRO/S'S_STREET PARCEL#(OFTIONAO S S7S �, Jv�rs GNT CITY NAME p STATE ZIP CODE 9 SITE PHONE#WITH AREA CODE G Sege/.� CA 9-s3 a-o �r�o9 7�5-396c0 TORN ICABox COR TION 0 INDIVIDUAL 0 PARTNERSHIP Q D15T I-GENCY 0 COUNTY-AGENCY � STATE-AGENCY I] FEOEANL#GENCY VIE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.s(optional) RESERVATION 3 FARM Z Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) /_I fZ. v c79- 785.39 a NIGHTS: NAME(LAST, Si) PHONE WITH AREA CODE NIGHTS: NAME(LAS 1.FIRS T) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa biMba* Q INDIVIDUAL 0 LOCAL.AGENCY C::] STATE-AGENCY C" 30X yb y QCORPORATION Q PARTNERSHIP 0 COUNTYAGENCY 0 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE tfI CO. a$ 3o9- 785- S7x0 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Eaa WmicaN INDIVIDUAL LOCAL-AGENCY STATE-AGENCY O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE IV.BOARD 0 UST STORAGE_FOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) CQ 4 F4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ba b1 SELF-INSURED Q 2 GUARANTEE 7 4 SURETYBONO D S LETTER OF CREDIT Q 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: 1.❑ II.E577III-❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE TIONAL =S -OPTIONAL TIONAL SUPVISOR-DISTRICT CODE -OP \ 55//tee oo-Y�a 3.2 /W 0. THIS FORM MUST BE ACCOMPAD BY AT LEAST(1)OR MORE PERMIT APPLIC ON• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A.5 �� NOW ��