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• • xe6o a e o0 e 4. STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD a�«,�' v 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �.n ,,, ., o COMPLETETHIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE FMARK ONLY 6 TEMPORARY SITE CLOSURE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT Q I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED)OF OPERATOR DBA OR FACILITY NAME NEAREST CROSS STREET PARCEL#(OPrx)NAL) ADDRESS , ✓ !/G/x1✓?^'n„I STATE ZIP CODE SITE PHONE k WITH AREA CODE 2 T CITY AME CA /m TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP [:D LOCAL-AGENCY E] COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#(optimal) TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATION O 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) ^' PHON�E#WITH AR CCODE _ DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) �/ PHONES ITH AREA CODE`l' NIGHTS: NAME(LAST,FIRST) pP.QN-1 sWITH AREA'C II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME /I� ✓ box bindkala INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY MAILING OR STREET ADDRESS CORPORATION = PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL-AGENCY STATEA ZIP CODED PHONE AREA CODE CITY NAME III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION Jl I/�l't G7Y� NAME OF OWNER ✓ box 0Indkale INDIVIDUAL LOCAL-AGENCYQ STATE-AGENCY MAIL GOR STREET ADDRESS Avt -A /ox .7 ' 0 CORPORATION ZIP PARTNERSHIP COUMYAGEITH EI] FEDERAL-AGENCY CITY NAME �1A/A�C/( STATE ZIP CODE _ ti PHONE WITH AAC'O�DE' IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3233--955555 if questions arise. TY(TK) HO 4T4_] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED 1SELF-INSURED 2 GUARANTEE O 3 INSURANCE 0 4 SURETY 83ND ✓ box bintlkale 0 5 LETTER OF CREDIT (�6 E%EMPTION 0 99 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 TflUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANT'S TITLE DATE MONTHMAY/VEAR LOCAL AGENCY USE ONLY CODUmNNTTY IT JURISDICTION# FACILITY# LOCATTIIIONCOOE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE - 0 Z� THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1]I—OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91)