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eu y - STATE OF CALIFORNIA 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EAC FACILITYISITE ED SIT it NEW�PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS MARK ONLY - ❑ — ❑ ❑ �y ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) v DB RFACILITY NAME NA OFOPERATO +o f eC ADD /O I N E i OSS STREET -PARCEL X(OPTIONAL) CI j>1151 4-o STACA ��O YYZI /$ITE P_� NE#WITHA CODE STO DISC TE f�CORPORATION Q INDIVIDUAL f�PARTNERSHIP O LOCAL-AGENCY f� COUNTY AGENCY 111 STAA�TEAGENCY Imo.FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ / IF INDIAN RESERVATION #OF TANKS AT SITE E.P.A. 1.D.#(optional) 3 FARM ❑ 4 PROCESSOR o 5 OTHER OR TRUST LANDS 3 IM —IU EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAh NAME(LAST.r �oPONEaWITAREACOIL+i� '(LAST,FIRS co9f8- �5a9Ja NPHONE I WITH AREA rnnp HT N)L/1 T,FIRST) O PHONE#WITH AREA CODE f11�G f NAME T) FAS II. PROPERTY OWNER INFORMATION• MUST BE COMPLL/SETED NAME/Y , /1 _ CARE OFkSIDRESS INFORMATION MAILINGOR TREE AD E S ✓bNIcIndlcau O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY f1 16tafl_e o 51 I ' e (YY =CORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STAIE ZIP CODEPHONE#WITH AREA CODE COM Ch I RSao a ao� q s- r741 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N FOWN R � ' I /f � CARE OF ADDRESS INFORMATION MAILING OR TREE ADDR S /V ✓ box 0indkeU INDIVIDUAL LOCAL-AGENCY STATE-AGENCY qn L CIME ha �W ` _ --- SI�ERPoRA7IZIP CODOE PARTNERSHIP PHOCOUNE#W HAREAOCODDERALAGENCV 9�aaa - IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ F41-41- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boxb indicate O 1 SELF-INSURED 712 GUARANTEE = 3 INSURANCE Q 4 SUREN BOND D 5 LETTEROFCREDIT [-16 EXEMPTION Ej'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.Ez II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLI 'S NAME RINT Pit SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR OCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY 41,31 LOCATIONCOOE -OPTIONAL CENSUSTRACT# - TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL o THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF S INFORMATION ONLY. FORM A(5-91) FOR0033A-5