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• peboon e STATE OF CALIFORNIA a oii STATE WATER RESOURCES CONTROL BOARD a ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y' COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANEN L CLOSED IT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILI N ME NAME OF OPERATOR � L • � ADDRESS NEAREST CROSS STREET PARCEL#(OPrgNAq 3 /_OL/>—S CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE YV\ uV1 CA 85336 ✓ BCA CORPORATION INDIVIDUAL I� PARTNERSHIP LOCALAGENCY D COUNTY-AGENCY 0 STATE AGENCY FEDERAL TO INDICATE DISTRICTS TYPE OF BUSINESS ❑ L GAS STATION ❑ 2 DISTRIBUTOR ❑ R SEIRF INDIAN VATION #OF TANKS AT SITE I E.P.A. I.D.#(optimal) O 3 FARM [_jj 4 PROCESSORTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) �cr 1.c� X1(9 613663a WITH AREA CODE NIGHTS: NAME(LAST,F RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION D}c�� 10 _\ MAILINGOR STREET ADDRESS / /n� //�� ` ✓box MIAH) 0 INDIVIDUAL E::] LOCAL-AGENCY 0 STATE-AGENCY (�a Sro y\Pr d L ill 8�re Z []'CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE�6 PHONE#WITH AREA CODE /) f 1 e 4 �L}✓L kali " / III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box WM aw 0 INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY Q CORPORATION l= PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME S7:7 CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. 4 n TY(TK) HQ 4 - /V A V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bmbiMkate 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND D 5 LETTEROFCREDIT =6 EXEMPTION 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.❑ it.❑ 111.❑ 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# FACILITY# , \F 1'Y I GIy 3 I 3 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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) - FOR603ZA-5 J