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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD syr' /UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ✓// ti Nor COMPLETE THIS FORM FOR EACH FA ISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCELA(OPIX)NAL) CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA CODE ��l ca 9Sao� 'Pal-,pj3-,l TO INDBOXICATE O CORPORATION CD INDIVIDUAL Q PARTNERSHIP DISTRICTS QAL-AG CY COUNIYAGENCY STATEAGENCY FEDERAL-AGENCY AN 1 TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / ❑ RESERVATOION %OF TANKS AT SITE E.P.A. I.D.%(optimaq ❑ 3 FARM Q 4 PROCESSOR EJ'55 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE%WAREA CODE DAYS: NAME(LAST,FIRST) ,/Pit 5 I""eej NIGHTS: NAME(LAST.FIRST) PHIAE%WI I H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION lv MAILING OR STREET AD R S / 550 Opxb Wicam =INDIVIDUAL LOCAL-AGENCY STATE-AGENCY e !J -0 CORPORATION 0 PARTNERSHIP E3 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME1/A �TE ZIP CODE / / PHONE%WITH AREA CODE 4 (e- COlO l (SOU YS III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION �p Y/ MAILING OR STREET ADDRESS Vbv nim"Ie OINDIVIDUAL OLOCAL-AGENCY ED STATE-AGENCY =CORPORATION O PARTNERSHIP (]COUNTY-AGENCY 0 FEDERALAGENCY 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 ✓ mxniMnaN (� I SELF-INSURED (]2 GUARANTEE0 9 INSURANCE (]a SURETY BOND 5 LMEROFCREDT =6 EXEMPTION Q 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: I.❑ 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 B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAY/VEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FAICI�LITTY�4 11111 LOCATION CODE TIONAL CENSUS TRACT% -,OrNAL ISUPVISOR-DISTRICT CODE -OPTIONAL /Y/y THIS FORM MU§T BE ACCOMPANIED BY AT LEAST ((111))OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) OROGGA-5