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• • �eaoun o STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH ACILITYISITE °�•�.per. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ks ADDRESS NEAREST CROSS STREET PARCEL 0(OPrIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA 9 S v r- ve-S3SX I/ Box TOINDICATE D CORPORATION D INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY O COUNWAGENCY D STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#ropfiWap 3 ARM 4 PROCESSOR 5 THER ❑ RESERVATION ❑ FO OOR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:'NA/ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) T/ l`Z C rrcc.. GGI�oS p' -.5-3.3� NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME -5-,r4-5-,r4 .. x-1 4 S �� CAPE OF ADDRESS INFORMATION ma ,�— MAILING OR STREET ADDRESS ✓ boXION le 0 INDIVIDUAL 0LOCAL-AGENCY 0STATE-AGENCY CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 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 r R 6✓1�P MAILING OR STREET ADDRESS ✓ box b Indicate [_3 INDIVIDUAL 0 LOCAL-AGENCY O STATEAGENCY O CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY Q FEDERAL-AGENCY CITU 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 - V. PETROLEUM UST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED 7_Z;_Eox binElcak 1 SELF-INSURED 0 2 GUARANTEE [-1 3 INSURANCE Q/SURETY BOND O 5 LETrEROFCREDIT 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 11 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 APP LICANTS NAME(PR INTED&S IGNATURE) APPLICANTS TIT LE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# HfIC evNil / aYo LOCATION CODE -OPTIONAL CENSUS TRACT# -O�P77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL PO �+� 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(5.91) FOROD33A(.55 • • `/� — )