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a rI 5STATE OF CALIFORNIA^ STATE WATER RESOURCES CONTROL BOARD/v/ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH F ITYISITE MARK ONLY F-1 I NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 99 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR IvP�-S �¢ CC/✓�en7� GU ADDRESS l NEAREST CR SS STREET PARCEL#(OPTIONAL) G,shr— IVA IVRv v Z> CITY NAME /- - STATE 21P CODE SITE PHONE#WITH AREA CODE ^0��-C7 ✓ Box TOINDCATE D CORPORATION D INDIVIDUAL (] PARTNERSHIP LONCV Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCYDISTRICTSTRICTSTRICTS TYPE OF BUSINESS O T GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION 0 3 FARM 4 PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA CO IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME _ vs ' CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindicate D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY .01 D CORPORATION O PARTNERSHIP D COUNTY-AGENCY E-1 FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHO E WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER -T- CARE OF ADDRESS INFORMATION A MAILING OR STREET ADDRESS ✓ box a Indbaw 0 INDIVIDUAL (] LOCAL AGENCY O STATE-AGENCY O 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 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ box biM1.1a I SELF-INSURED [_1 2 GUARANTEE 0 3 INSURANCE 0 4 SURETYBOND O 5 LETTEROFCREDIT 0 6 EXEMPTION O 93 OTHER A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or-Lis4keek6d. CHECKONE 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) APPLICANT'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If FACILITY � (VERaa LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -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. FORMA(5-91) F