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• • >eyouu � STATE OF CALIFORNIA ^+ STATE WATER RESOURCES CONTROL BOARD �s., 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �`� v s ., id> COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY D SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY rkWE NAME FOPERATOR c�J� FARMS eo . A- 5Po,e�� ADDRESS NEAREST CROSS STREET PARCEL#(OPFIONAL) 2 0 663 v I� € Z_ R CITY NAME STATE ZIP CODE A�TE PHQeNE#WITH AREA CODE Gd i T CA Z zp'�u 365- ✓ BOX TOINDICATE O CORPORATION INDIVIDUAL =PARTNERSHIP O LOCAL—AGENCY OCOUNTY-AGENCY OSTATE-AGENCY DFEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS _ 1 GAS STATION ❑ 2 DISTRIBUTOR 1❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) FARM 4 PROCESSOR 5 OTHERe OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME LLAST,FIRST) �x 1 PHONE#';1W 1 AREA CQDE Y DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE A NIGHTS: NN•M`MEE(LAST,FIRST) PHONE!#WITTHLAREA—COOODDEEE NIGHTS: NAME(LAST,FIRST) IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION liz RAILING OR STREET ADDRESS ✓ box bindkale INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY =CORPORATION = PARTNERSHIP ED COUNTY-AGENCY = FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION S� Y SP F- .4 MAILING OR STREETADDRESS ✓ box 0Wicks INDIVIDUAL O LOCAL-AGENCY Q STATEAGENCY Q V �/�• l=CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY ITY NAME / STATE/N ZIP CODE �� ONE#N(ITH AREA CODE // t 4 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ F4]-4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bindloaN I= 1 SELF INSURLD 2 GUARANTEE 3 INSURANCE 4 SURETY BOND IL3 5 LETTER OF CREDIT 6 EXEMPTION 0 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 APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY At LOCATION CODE -OPTIONAL CE3TRACJ#_OPTIONAL SUyOISTRICT CO� _ / q,91 1 THIS F RM 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) FORS