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r STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD -- UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °4,•onn,n COMPLETE THIS FORM FOR EACH fA YlSITE - MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMANE CLOSED SITE ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT � e TEMPORARY SITE CLOSURE S3 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME -� NAME OF OPERATOR [ IGC 5 Y/lJ-�V /Z-e cc�v ADDRESS � f NEAREST CROSS STREET PARCEL IOWgNAq CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE I/ Box SA, c /-b CA -5- TOINDICATE O CORPORATION 0 INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR = "' IF INDIAN #OF TANKS AT SITE E.R A. L D.#Wicnao RESERVATION / Q 3 FARM Q 4 PROCESSOR a 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE= LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) # II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box buWkale O INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 0 CORPORATION PARTNERSHIP O CWNry.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 MAILING OR STREET ADDRESS ✓ bor biWxa I] INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION Q PARTNERSHIP [_1 COUNTY-AGENCY PEDEPAL-AGENCY 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) HQ 74F4-1- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOO(S) USED ✓ box binokab O I SELFINSURED =2 GUARANTEE 3 INSURANCE O 4 SURETY BOND (]5 LETTEROFCREDIT Q 6 EXEMPTION 0 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 APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m I KF_S VJ3 ?U iaY LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL U ! �) 5f'8 I 3d //'3U THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHONLY. FORM A(5.91) CHANGE OF SITE INFORMATION /`/� � FOR0077A5