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\ • • w�°�u..w co `VL/e STATE OF CALIFORNIA y l� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA �, o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NNnn II- NEAREST NAME OF OPERATOR � p✓ICI ,11CA-e �✓1 J ADDRESS C SS STREET PARCEL Y(OPTIONAL) el - CITY NAME t STATE IT PHON�WITH A C�� T 01i Gf J O TO I/ BOX l�CORPORATION INDIVIDUAL F7 PARTNERSHIP LOCAL-AGENCY O fl-AGENCY D COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY TYPE OF BUSINESS �GA3 STATION 2 DISTRIBUTOR O ICTS ✓ IF INDIAN p OF TANKS AT SITE E.P.A. I.D.%(optimaq ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) ^ PHONEALWITH AREA CODE PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST( V/l /C PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME ` CARE OF ADDRESS INFORMATION rpter+ Ohvl F°lkv^i °L MAILINGO(STREET ADDRESS ✓ box blMlcab 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY Zz CORPORATION PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME J STAP7 ZIP CODE PHONE#WITH AREA CODE D (: J III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicaW 0 INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY CORPORATION D PARTNERSHIP l=COUNrYAGENCY (] FEDERAL-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 F4]4 - V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box 0 Micab O 1 SELF-INSURED 0 2 GUARANTEE E-1 3 INSURANCE L_j 4 SURETY BOND D 5 LETrEROFCREDIT 0 6 EXEMPTION O IH 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.❑ Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APP LICANTS NAME(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION* FACILITY# /U -7 7. m 2 6 LOCATION CODE -OPTIONAL SUS TRACT# -OPTIONAL SUP'IN-DI RICT E -OPTIONAL —�� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL ' FORM A(5.91) FOR A3