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`� E40Uw f3 STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EA FACILrTYISITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE 15O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONALI Alf or" War Mq* - CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CODE e CA 2 - - u v BOX TOINp TE CORPORATION INDIVIDUAL (]PARTNERSHIP 0 D6TfliC LOCAL-AG0 COUMVAGENCY 0 STATE AGENCY 0 FEDERAL AGENCY TYPE OF BUSINESS O 1 GAS STATIONRESERVATION 2 DISTRIBUTOR O ✓ IF INDIAN Y OF TANKS AT SITE E.P.A. I.D.%(oplicnal) Q 3 FARM O 4 PROCESSOR = 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) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CA RE OF ADDRESS INFORMATION - CrA7 o u66 Gdw1FS �' ,�ctrr 'f MAILING UOR STREET ADDRESS ✓box 0Wiute INDIVIDUAL O LOCAL- ENCY TE-AGENCY /,Z S— N• E-/ Perac, O CORPORATION O PARTNERSHIP M COUNTYAGENCY 0 FEDERALAGENCY CITY NASTATE ZIP CODE PHONE#WITH AREA CODE ME o,k C4 III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME O—F._OW��NER CARE OF ADDRESS INFORMATION .D�// MAILING OR STREET ADDRESS 7 box NNidkaN OINDIVIDUAL LOCAL-AGENCY MSTATE-AGENCY 0 CORPORATION O PARTNERSHIP D COUNTY-AGENCY M FEDERALAGENCY 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 0 3 2 2 2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box b indicate D I SELF INSURED O 2 GUARANTEE LD2] INSURANCE 4 SURETY SOND 0 5 LETTEROFCREDn O 5 EXEMPTION L 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.❑ IL 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) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY* JURISDICTION# - �yH , LOCATION CODE/-OPTIONAL CENSUS TRACTi -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ,2 3. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORSA 5 y ea J:\ ''�L