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• Ow STATE OF CALIFORNIA • `i STATE WATER RESOURCES CONTROL BOARD - g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORP" A j Y `I Nr COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 ERMANENT Y LOBED SITE CNE ITEM 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS 86 NEAREST CROSS STREET PARCEL 4(OPTIONAL) o L.a�� RO CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE I/ ROX CA q C3 76 TOINGC TE 0 CORPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY D COUNTY-AGENCY STATE AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ T GAS STATION 2 DISTRIBUTOR = IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optiona)) 3 FARM Q d PROCESSOR—Q-5-Oi+IER —�p7RUgTLpp - EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARYj,optlonal �7 YS: NAM (LAST,FIRST) J 7P HONE#WITH AR CODE DAYS: NAME(LAST,FIRST) - OY 4Fc1 c e W`%-ac S/2 3 NIGHTS: NAME(LAST,FIRPM PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE xWITH AREA COI II. RTY OWN€R INFORMATIGN- COMPLETE ----- - — NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blMkale (] INDIVIDUAL LOCALAGENCV STATEdGENCY O CORPORATION M PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0 Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY O CORPORATION PARTNERSHIP Q COUNTY AGENCY O FEOERAL-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) HQ 4 4 - b oZ 7 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ baab iMkffi O I SELF-INSURED = 2 GUARANTEE D ANCE O a SURETYBOND O 5 LETTEROFCREDIT 0 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: L II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YE�AyR '— <--/ 2 LOCAL AGENCY USE ONLY COUNTYK ,y/ fb JURISD�ICTIONp FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL v8� 3 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 15.91) FORW7.TA-5