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�I A �esoo« e o0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A rI , J G w COMPLETE THIS FORM FOR EACH CILrTYISITE MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT = e TEMPORARY SITE CLOSURE p I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR A7D �NEAREST /V�` STREET�V't'Y✓-�- PARCEL N(OPrM)NAL) CITY NAME STATE ZIP CODE ITE PHONE N WITH AREA CODE df/oa{� p CA 204)33a z ✓ BOA TO INDICATE CORPORATION INDIVIDUAL E�] PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR - O RESV IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(optiawl) 3 FARM Q 4 PROCESSOR 0 IOTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) e ,G_ ,577/_ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODEJ NIGHTS: NAME(LAST,FIRST) �— Q00N9#WITH AREA CO — J II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓�Ea!bl^AKaM L-1 INDIVIDUAL 0 LOCAL-AGENCY � STATE-AGENCY /QU_ � fARPORATION [::] PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE �� ;0c -HOZ-G�1/ /c) 1107 - 2-LG III. TANK OWNER INFORMATION- (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 7114GOR STREETpDDRESS ✓boa 0Intlkae INDIVIDUAL I� LOCAL-AGENCY I�STATE-AGENCY —('J CORPORATION 0 PARTNERSHIP COUKIYAGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE HONE#WITHAREA CODE / � G/ / c7G 7v2 '6�f/� /�fJ7-Z ti IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 O Q V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ X.Oimicaw 0 I SELF-INSURED I=2 GUARANTEE 0 3 1NSURANCE 4 SURETY BOND 0 S(ETrEROFCREDIT O e EXEMPTION 0 W 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: I. II. It O 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# A&04-1 LOCATION CODE -OPTIONAL CENSUS TR CT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL L•17 1Z- THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY. FORM A(5.91) FORW33A 5 /J