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STATE OFCALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLIC��TIO� F MA COMPLETETHIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Fv T PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR CILITY NAME ^ NAM CIPERATOR .� lie It, -rr ADOR 5DO -�e( �hU NEAREST CROSS STREET PARCEL#IOPFgNAL) �a. a CITY NAME STATE ZIP CO SITE PHONE#WITH AREA CODE CA I/ BOX TO INDICATE D CORPORATION L�l INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY E7 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optimal) ESERVION ❑ 3 FARM 0 4 PROCESSOR 5 OTHER OR RTRUST LATANDS EMERGENCY CONTACT PERSON (PRIMARY) 4 EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA Coop II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME 14 CARE OF ADDRESS INFORMATION r ' e- MAILIN ORSTREETADORESS ✓ box blMkate 0 INDIVIDUAL l= LOCAL-AGENCY O STATE-AGENCY l�CORPORATION O PARTNERSHIP =COUNTY-AGENCY E-1 FEDERAL-AGENCY CITY 114AMItSTATE ZIP ODE PHONE#WITH AREA CODE 5 o a - III. TANK OWNER INFORMATIO -(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box m lndleale D INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY D CORPORATION I7 PARTNERSHIP Q COUNTY AGENCY Q 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 METHOD(S) USED ✓ box w Ind,,Ae F-1 I SELF INSURED E�j 2 GUARANTEE L3 3 INSURANCE O 4 SURETY BOND E7 5 LETTFROFCREDIT 0 6 EXEMPTION 0 W 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.❑ I.= III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAM E(PR IN TED&S IGNATU RE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM M ST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A 5