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Xc • • STATE OF CALIFORNIA ��'^ STATE WATER RESOURCES CONTROL BOARD ;• UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :-� "° .e y.e o' 'jys . °-��.onna COMPLETE THIS FORM FOR EACH FACILMYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY grogmOMT11 ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT p 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) y wrai 0- ai L OBAORFACILITV ME /� NAME OF OPERATOR (A APA. G, a -Kew/ ADD ESSNEAREST CROSS ST�RE� PARCELA(OPTIONAL) , I`i 6 v o VT/I Lv I CIN NAME STACA ZIP CODE SITE PHONE A WITH AREA CODE Mwn�t 5 ✓ Box TO INDICATE �CORPORATION l�INDIVIDUAL Q PARTNERSHIP 0 D WCTS�CY Q COUNFEOERALAGENCV TV#GENCY Q STATE AGENCY O IF INDIAN 1 TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION A OF TANKS AT SITE E.P.A. I.D.I(optimal) Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: AME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) L�q_(` v M /^f zo �Z 3167 , L 'CPWQNP NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAM (LAST,FIRST) sS9- 17/ Zo 5 235- YJ,3 II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ��jj II CARE OF ADDRESS INFORMATION r A �q Ll fc0 �-F'— MAILING O TREET ET ADDD ✓ Dor biMkau Ej INDIVIDUAL O LOCAL-AGENCY 0STATE-AGENCY OQ CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE Ke,v c I t9 1 /5336 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION f✓✓/L MAILING OR STREET ADDREsbox 0indcale INDIVIDUAL a LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION PARTNERSHIP O COUNTY-AGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ F474 - p Z O V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bnX blMkale O 1 SELFINSURED O 2 GUARANTEE 3 INSURANCE Q a SURETY BOND =5 LETTEROFCREDrr Q 6 EXEMPTION Q 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.❑ II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 77)�,461—/V 3 s 5 LOCATION CODE -OPTIONAL (CENSUS TRACT$ -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOR0033A5 0 • /'