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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C--,---UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A Y; (y COMPLETETHIS FORM FOR EACH F RY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .Sb I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME ` NAME OF OPERATOR Su an F :!2 ,-) G ez7 ADDRESS NEAREST CROSS STREET PARCEL I&F NAU /6,/77 122 c E!n /e Z<.Pw CITY NAME STATE ZIP CODE BOX CA SITE PHONE#WITH AREA CODE LutiA 9Ss'3D ✓ TOINDICATE CORPORATION O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY (::] STATE-AGENCY (] FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.x(optimal) ❑ 3 FARM O 4 PROCESSOR O 5 OTHER R OR TRRUSTUSTLAN DD S EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bw bindka4 L-1 INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY D CORPORATION O PARTNERSHIP Q COUNTY-AGENCY C-1 FEDERAL-AGENCY CITY NAME STATE 21P CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ Dox binakale L–j INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY CITY NAME O CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY STATE Lie 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 - O a s p V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE M D(S) USED ✓ box b Mba4 E--] I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND 0 5 LETTER OF CREDIT 0 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 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II.❑ It.❑ 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 MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP7/ONAL 1 I a3 r �II. \ THIS CORM MUST E ACCOMPANIED BY AT LEA OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM AI+91J • FOR0033A-5