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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ;,a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , j o \1 COMPLETE THIS FORM FOR EACH FACILITY/SITE 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 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D AOR FACILITY NA NAME OF OPERATOR F 'P2 1° ADDRESS NEAREST CROSS STREET PMCELpIOPTIONAQ CI AM STATE ZIP CODE IT PHONE WITH AREA CODE CA 3 Op�ay 37/ TO INDICATE O CORPORATION D INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCYDISTRICTS IF INDIAN 1 O COUNTWAGENCY D STATE-AGENCY FEDERAL-AGENCY TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) O 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH A EA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAM E(IAST,FIRS T) PHONE#WITHARE CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COM ETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ hox mindmaU D INDIVIDUAL O LOCAL-AGENCY STATE AGENCY Q CORPORATION O PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER ARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ]bW-Wlndkale 0 INDIVIDUAL O LOCAL-AGENCY [_1 STATE-AGENCY ( ORPORATION O PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-C1( 916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETEENTIFY THE METHODS) USED ✓ box pindkale I= 1 SELF-INSURED 12 GUARANTEE 0 3 INSURANCE (] 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sen to thetank owner unless box 1 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&SIGNATURE) APPLICANTS TITLE \ DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT; -OPTIONAL SUPVISOR-DISTRICT 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(5-91) (7 -a 3 j _# OR ��0 1