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DBA OR FACILITY NAME •• ,� 1 PHONE WITH AREA CODE ., �,. K- ..y. MAILING OR STREET ADDRESS ✓ cafe INDIVID AL -AGENCY STATE -AGENCY �. PHONE a WITH AREA nonp ADDRESS " PH E # iTH AREA CODE �$,, NEAREST CROSS S i *E - -- --- PARCE4W0PP0 U. 0 COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME STATE OF CALIFORNIA StA Em �P .-PHONE WITH AREACODE ` STATE WATER RESOURCES CONTROL BOARD ZIP CODE SITE PHONE # WITH AREA CODE "CA UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA w '� a CA 53��, Zc l l $l S .)6) 5 ✓ BOX CORPORATION TO INDICATE I� INDIVIDUAL I_ PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY Q STATE -AGENCY 0 FEDERAL -AGENCY COMPLETE THIS FORM FOR EACH FACILITY/SITE DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR MARK ONLY F_-] 1 NEW PERMIT F_� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E::] 6 TEMPORARY SITE CLOSURE �i I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME } - PHONE WITH AREA CODE NAME OF OPERATOR MAILING OR STREET ADDRESS ✓ cafe INDIVID AL -AGENCY STATE -AGENCY PHONE a WITH AREA nonp ADDRESS " PH E # iTH AREA CODE �$,, NEAREST CROSS S i *E - -- --- PARCE4W0PP0 r� 0 COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME 0o 60 StA Em CITY NAME .-PHONE WITH AREACODE ` STATE ZIP CODE SITE PHONE # WITH AREA CODE "CA CA 53��, Zc l l $l S .)6) 5 ✓ BOX CORPORATION TO INDICATE I� INDIVIDUAL I_ PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY Q STATE -AGENCY 0 FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) 3 FARM 4 PROCESSOR = 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optionlal DAYS: NAME (LAST, FIRST) NAME CAR ADDRESS INFORMATION-—— PHONE WITH AREA CODE DAYS: NAME (LAST, FIRST) 'too MAILING OR STREET ADDRESS ✓ cafe INDIVID AL -AGENCY STATE -AGENCY PHONE a WITH AREA nonp NIGHTS: NAVE ( f FIRST) STA PH E # iTH AREA CODE �$,, NIGHTS: NAME (LAST, FIRST) �� �t 6r "1PHONE ► r� 0 COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME OL II. PROPERTY OWNER INFORMATION -_ MUST BE COMPLETED III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CAR ADDRESS INFORMATION-—— 'CARE OF ADDRESS IN ORMATION MAILING OR STREET ADDRESS ✓ cafe INDIVID AL -AGENCY STATE -AGENCY CORPORATION 0 PARTNERSHIP 0 .COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STA 0 LOCAL -AGENCY STATE -AGENCY QIP CODE ONE WITH EA CODE ( CORPORATION PARTNERSHIP 0 COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME 0o 60 StA Em III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER ``kms 'CARE OF ADDRESS IN ORMATION DATE ON DAYIYEAR MAILING OR STREET ADDRESS (� ✓ box to indicate 0 INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY C} , ,� lj ,9 ( CORPORATION PARTNERSHIP 0 COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME „-� StA Em Z PCODE jam,, � p .-PHONE WITH AREACODE ` o IV. BOARD OF EQUALIZATION UST STORAGE FEE, A= OUNt NUMBER Coif (916) 23-9555 if questions - TY (TK) HQ [4F4]_j f .) (` Cj p: V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST BE COMPLETED IDENTIFY THE METHOD(S) USED } I/ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND ai 5 LETTER OF CREDIT 0 6 EXEMPTION 99 OTHER r VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. Am [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. E] III - THIS FARM HAS 404 COMPLETED UNDER PENALTY OF PERJURY, AND TO,THE BEST OF MY KNOWLEDf & IS TRUE AND CORRECT, # " WO; APPLICANTS NAME(PRINTED & SIGNATURE) ``kms APPLICANTS, DATE ON DAYIYEAR LOCAL AGENCY USE ONLY :ry COUNTY # JURISD�ICTIONj # t, 6CILITY At LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - C077ONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. FORM A (5-91) FOR003: