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• • peeoon e STATE OF CALIFORNIA o^ STATE WATER RESOURCES CONTROL BOARD s o C/ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A en < o C�tl�Oe M,n COMPLETE THIS FORM FOR EACH FACILfTYISITE MARK ONLY F--j 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL S E ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR %4 C w'a �LiC UA'' e ADDRESS NEAREST CROSS STREET PMCEL#(OPTKINALI / Lfe>0 o i r; y CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 4� e rS CA `f5 33d TOINDIBOX O CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY f� COUNTY AGENCY f�STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE IN BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 gESERVADTION OF TANKS AT SITE E.P.A. I.D.#(opfimalJ O 3 FARM 4 PROCESSOR �THER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional / DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME LAST,FIRST) ApCf 8-23-3147 PHONF S WITH AREA CODENIGHTS: NAME(LAST.FIRST) f PHONE#WITH AREA CODE NIGHTS: NA l.FIRSTry � -Q�b� p � 9tf93 NF#WITH AREA CODE / - It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDR SS ✓ box b indicate Q INDIVIDUAL = LOCAL-AGENCY ff STATE-AGENCY O L7 =CORPORATION PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCYCITY NAME // Cl STAJJ� ZIP CODE 3 PHONE#WITH AREA CODE //le co L �- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINGOR STREET ADDRESS ✓ Wx biwicala = INDIVIDUAL = LOCAL-AGENCY STATE AGENCY 1�CORPORATION = PARTNERSHIP 0 COUNTY AGENCY 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 WrAcala = 1 SELF-INSURED =2 GUARANTEE [-13 INSURANCE 4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION O 99 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.0 II.�. 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 It JURISDICTION# FACILITY ILI S 3 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ZI � .2- ✓THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION•I�FORM B,UNLESS THIS IS A CHANGE OF SIT E INFOfl T N ONLY. FORM A(5-91)