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STATE OFCALIFORNIA CON STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE�.{ ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5✓ I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA) ICILITVNAME a/1�-/ /y _ .�.�,^ �Q NAME OF OPERATOR ADD 2 1LY^Y//ZL hl' /l•Y/Ja �a ' ar I �( NEARES CROSS STREET PARCEL$(OPrIONAL) CITY ,. J_ STATE ZIP C I^ SITE PHONE a WITH AREA CODE ✓ Box \✓71 CORPORATION ✓hY-AGENT TOINpCATE O CORPORATION D INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#roptionap ❑ 3 FARM ❑ d PROCESSOR ❑ 5 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional FYS : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRSnTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM /j. CARE OF DDRE$S,INFORM/T710N�� q J MA GgR$THEET�DRESS /•�� ✓boa bindicak/`J-E7•� INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY I o/� I L('JJj( +\ 0 CORPORATION O PARTNERSHIP =COUMV-AGENCY E-D FEDERAL-AGENCY CITUd STA ZIPQODE�� 69 PONE WITH AR CODE6,a,a' III. TANK OWNER INFORMATION•(MUST BE COMPLETED) Z JS /'1/ NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa bbdicale D INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 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 7474 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓ xxiohdicale I SELF-INSURED Q UARANTEE Q 3 INSURANCE 0 d SURETY BONO 5 LETTEROFCREpT Vr6 EXEMPTION 0 IN OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i ecked, CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.vIII. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APP L ICANTS NAME(PH INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# _QDm40__ JURISDICTION# FACILITY# a?] Avmz8 [:J:]� j_+qz LOCATION COODE -OPTIONAL CENSUttW'* yQPjJ•ONAL SUPVIGOR-DI ST RICTCODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE ONLY.. FORM A(5-91) FOflO`0-3-�iAA 5�