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�eoo^ e STATE OF CALIFORNIA Wc• STATE WATER RESOURCES CONTROL BOARD w��, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY ITE ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE �3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME _ NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 60 !� CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA -f 33--B/f/ I/ BOX T NDCATE CORPORATION DIVIDUAL =PARTNERSHIP O LDCAL-AGENCY O COUNrYAGENCY F] STATE-AGENCY 0 FEDERALAGENCY D TRICTS TYPE OF BUSINESS = 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(mlmal) 3 FARM 4 PROCESSOR OTHER RESERVATION f� f� OR TRUST LANDS If EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA OCIDIE DAYS: NAME(LAST.FIRSyT1 - NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bosbirdkab ED INDIVIDUAL 0LOCAL-AGENCY-= STATE-AGENCY CORPORATION [::] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-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 -5'q —41 �— MAILING ORSTREET ADDRESS ✓W.0micaN INDIVIDUAL E:] LOCAL-AGENCYSrATE-AGENCY f�CORPORATION PARTNERSHIP E::] COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Dox biiMicale 1 SELF-INSURED lD 2 GUARANTEE E71 ] IN CE !SURETY BOND O 5 LETTEROFCREDIT 0 5 EXEMPTION OTHER 771 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: 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# FACILITY# 1J I CE LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -O zs THIS FORM MUST BE A COMPANIEO BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. V_ FORM A(5-91) FORDMA5