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STATE OF CALIFORNIA • ,P �'^ a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A / r C�[IFOP N1 r COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C D S ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �// I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) S DBA OR FACILITY NAME iilNAME OF OPERATOR Ilore ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ✓ BOX TO INDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR R SERVATION OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS b EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) Aw. C,c.s5i '.2- I L M-L1 7 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA Con II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION '-1v4L - Pk) (d r6,e. U MAILING OR STREET ADDRESS ✓ x to indicate INDIVIDUAL E:] LOCAL-AGENCY ED STATE-AGENCY 5 L L; U 3 CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION L-VT" R MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY [- - d CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATECODE PHONE#WITH AREA CODE sz G ZIP 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 b indicate 1 SELF-INSURED (]2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT 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.= II. III. 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) APPLICANT'S TITLE DATE MONTH/DAYNEAR tn - 3 0 .-9 3 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE ITIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MU§T 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) FOROMM-5 IdaAv �3 �� I l-9-93 sQ 0 • 1,'__,1