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STATE OF CALIFORNIA • ^p``��•• °+ STATE WATER RESOURCES CONTROL BOARD t 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A • �`� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ID DBA ORFACILITY NAM NAME OF OPERATOR ADDRESS f �, do E � � NEAREST CROSS STREET PARCELa(OPTIONAq CI NAME STATE ZIP CODE SI E PHONE#WITH AREA CODE ^ Fat CA q ,/ )72 7-S3ob ✓ Boz TOINDICATE 0 CORPORATION INDIVIDUAL D PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTOR '/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfianal) 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER O RESERVATION Z OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME((LAST,FIRST) ONE#WIT Z71EA C9 DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRSPHUNNIIE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM CARE OF ADDRESS INFORMATION MAILING OR STREET DRESS /-� ✓ boxblmk jZrINDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY v . O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCYCITU NAMED f� STT ZIP CAD PHONE#WITH AREA CODE III.. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM>E GF OW Efl CARE OF ADDRESS INFORMATION MAILING GR STREET ADDRESS ✓Eox b intlbab LOCAL-AGENCY r INDIVIDUAL EJ STATEAGENCV I �, CORPORATION Q PARTNERSHIP COUNTY-AGENCY E AGENCY CITY NAME STATE ZIPCOD HONE WITH AREA CODE-_7 7 7 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 ✓ box b indicate O 1 SELF-INSURED =2 GUARANTEE O 5 LETEROFCREDIT 0 ]INSURANCE O /SURE BOND (]6 EXEMPPON Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent t0 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.❑ II.❑ III.❑ THIS FOAM 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 MONTHIDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILI -� LOCATION CODE -OPTIONAL CEN$ySTRACj#-OPTIONAL SUP IS R-DI TCODE -OPTIOM 7 ?,7 FORM THIISSFORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SRE INFORMATION ONLY. 0 • �1%(/ FIXi0079k�