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STATE OF CALIFORNIA ^aw„• e ° STATE WATER RESOURCES CONTROL BOARD 1a -� a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "`� v; e YI . o' • °••,.may COMPLETE THIS FORM FOR EAC ACILITY/SITE ��.y[[ MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE SO I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITY NAME / NAMEOFOPERATOR /7 I`fRit /17'C ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIINAL) CITY NAME STATE ZIP CDy� SITE PHONE WITH AREA CODE on CA T 532c� ✓ BOX TO INDICATE ED CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY (] COUNTY-AGENCY STATE-AGENCY Q FEDERALAGENCY DISTRICTS TYPE OF BUSINESS = 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L D.#(opIknQ PESERVATION 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITHA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHT$: NAME(LAST,FIRST) if""?%' z W 5 356 II. PROPERTY OWNER INFORMA ION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION 1�904 `1` f/ MAILING OR STREET ADDRESS ✓OMbilbba4 �'INDrvIDUAL IOCALAGFNCY STATE-AGENCY JT 0 CORPORATION = PARTNERSHIP = COUNTYAGENCY 0 FEDERAL-AGENCY CI AME STA HONE#WITH AREACOOE T)9 ZIP CODE 95zzf1 s-3%6v III. TANK ANER INFORMATION-(MUST BE COMPLETED) NAM OF OWNER 11 CARE OF ADDRESS INFORMATION I[rfi TC MAILING OR STREET ADDRES49 box b lnOkau INDIVIDUAL O LOCAL-AGENCY (]STATE AGENCY D. ,�X 7oY Q CORPORATION 0 PARTNERSHIP (]COUNTYAWNCY (] FEDERAL-AGENCY CITY NAMESTATEZIP CODE PHONE#WITH AREA CODE (O IV.r1f0ARtf OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ F4174 - c9 3 z 61 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eo�biMiMu 1 SELRINSURED O 2 GUARANTEE 0 3 INSURANCE (]A SURETY BOND O 5 LETTEROFCREDIT =8 EXEMPTION O 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.� 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) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACIL"# 9] I I ILIJ-51-7101 LOCATION CODE -OPTIOIIWI. CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL (l(9 'Z's -z'Z J 7W/ 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 IS-9/1 FOR8813A-;