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a • STATEOFCAUFORNA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q T PERMANENTLY CLOSED S1TE ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA NA ORF ILITY ME NAME OF OPERATOR G Inoue � I� ADDRESS NEAREST CROSS STREET P a vl �ti CITY NAME � STATE ZIP CODE SI H ITH AREA DE �C TJ CTAI/ BOX T NDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY.AGENCV• Q STATE-AGENCY- Q FEDEMLAGENCY' If miter of UST Is a Public agency,complete the following:name of Supervisor of division,sedan,DISTRICTS or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INVATION ULA N A OF TANKS AT SITE E.P.A. I.D.a Npf/araQ Q 3 FARM 0 4 PROCESSOR 0 5 OTHRESER ER OR TRUST LANOS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME SLAST,FIRST) PHONE 8 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION 1 rn thy' �d! I)_ rC� � ) (' . ,grvMba-v ti hl I;GORSTREET ADDRESS ,(/n,(e ✓ Dor to Indicate Q INDIVIDUAL Q LOCAL STATE AGENCY 5/ S HIsL !\T/ IQ CORPORATION Q PARTNERSHIP Q COUNIY.AGENCY Q FEDEMLAGENCY CIN NAME j / STATE 21P CODE P ONE S WITH AREA CODE 5'c rnm� >iJ �� 6 �J/- S50v ggg� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Q YvI GS ] MAILING OR STREET ADDRESS ✓ bo�0indicata Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY i Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERALAGENCY If1 CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. 1 TY(TK) HQ [4T4- - L J� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa b Indicate Q I SELF-INSURED 10 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q S EXEMPTION 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. 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 OWNER's NAM E(PRINTED&S IGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTYLY JURISDICTION V FACILITY• IL LOCATIONCODE .OPTIONA CENSUS TRACTS -OPTIONAL SUPVISOR- ICT CODE -OPTIONAL 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(3183) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR88730017 • __••••^n�Gv Or N Ycnn... ... FILE THIS FOAM tarn •�, ..._