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STATE OF CALIFORNIA .°gO.•.,; o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM �a ag y'. COMPLETE THIS FORM FOR EACH FACILITYISITE D ""� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ONE ITEM E] 2 INTERIM PERMIT ❑ E] T PERMANENTLY CLOSED SITE ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME %A ICR. NAME OF OPERATOR ADDRESS S .S NEAREST CROSS STREET ,��s�- PARCEL$(OPTIONAL) S' • , CITY NAME / M r„- STATE ZIP CODE SITE PHONE$WITH AREA CODE ✓ eox CA 9'53-7 6 TOINCICATE ORPORAnON 4 NDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY DISTRICTS O FEDERALAGENCY TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfiwal 3 FARM RESERVATION Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME LAS EMERGENCY CONTACT PERSON (SECONDARY)-optional ( T,FIRST) O PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: N ME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED)# NAME W &f— (^i�` r 6 A0j CARE OF ADDRESS INFORMATION MAIL67" NG STREET ADDRESS ✓ Doc bale C jjN0 E ^ INDIVIDUAL (] LOCAL-AGENCYQ STATE-AGENCY CITY A DTf fCORPORATION PARTNERSHIP Q COUMVAGENCY Q FEDEMLAGENCY OpOSTATE ZIP CODE PHONE#WITH AREA CODE . O Gtr— III, TANK OWNER INFORMATIO -(MUST BE COMPLETED) NAME OF OWNER -SA-mg- A-s CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Dox bindkale Q INDIVIDUAL O LOCAL-AGENCY I=STATE-AGENCY CITY NAME CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEDEIRL-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE IV,BOARD OF EQUALIZATION UST TY(TK) HO 4 4 - STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. Q 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ taxbindkau Q I SELF-INSURED (]2 GUq"AMEE Q 3 INSURANCE 5 LETTEROFCREDIT I EXEMPTION O<SUgETY BOND 93 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent t0 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: 1.❑ 11.❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATUflE) APPLICANTS TITLE DATE MONTWDAV/YEAR LOCAL AGENCY USE ONLY---------------- C� COUNTY# JURISDICTION# FACILITY# © w112Y LOCATION CGDE -OPTIONAL (CENSUS TRACT# -OPTONAL 3� ISUPVISOR-DISTRICTCOOE -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) fOR0077A5