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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE go MARK ONLY3�91NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L] 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NAME OF OPP�€€RATOR JA -J AIM MAILING ORr STREET ADDRESS I ` � NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE -W ] CORPORATION PARTNERSHIP ADDRESS p 74 i,_�s C,?A..S► L.r1F_- CITY NAME NEAREST CROSS STREET eA4_aut PARCEL # (OPTIONAL) CITY NAME PHONE It WITH AREA CODE d -g3 - 3411� STATE ZIP C E � SITE PHONE # WITH AREA CODE 1-1-VA1-. CA CTS3 E2 61,91- -31i6 ✓ BOX ] CORPORATION ] INDIVIDUAL LKJ NARTNERSHIP Q LOCAL -AGENCY (] COUNTY -AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS ' M owner of UST is a public agency, complete the following name of supervisor d division, sedan or office which operates the UST TYPE OF BUSINESS �1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN RESERVATION # OF TANKS AT SITE E. P. A. 1. D. # (optional) Q 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS . FMFRrFNCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE &—J6tA S act -3 4f 1/6 MAILING ORr STREET ADDRESS NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE Cjr a n) A C2 cpt— 6 & 3 ] CORPORATION PARTNERSHIP II- PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME I � ^ l \J CARE OF ADDRESS INFORMATION MAILING ORr STREET ADDRESS ✓ box to indicate IN VIDUAL (] LOCAL -AGENCY (] STATE -AGENCY _ ] CORPORATION PARTNERSHIP I] COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP ODES I fo CITY NAME —Q# PHONE It WITH AREA CODE d -g3 - 3411� LL PHONE # WITH AREA CODE 3- 3 NI TANK nW&R INFORMATION .(MUST BE COMPLETED) NAME OF OWNER _ CARE OF ADDRESS INFORMATION i IJ .A, MAILING OR STREET ADDRESS 4 ✓ boxto ndcate = INDIVIDUAL ] LOCAL -AGENCY STATE -AGENCY 6, CORPORATION 5ErPARTNERSHIP COUNTY -AGENCY ] FEDERAL -AGENCY CITY NAME —Q# STATE L ODE ! ZIP CQ S 3 7 PHONE # WITH AREA CODE 3- 3 o— IV. BOARD bF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) – IDENTIFY THE METHOD(S) USED ✓ box to indicate ] 1 SELF-INSURED [ 2 GUARANTEE ] 3 INSURANCE (] 4 SURETY BOND ] 5 LETTER OF CREDIT ] 6 EXEMPTION Ib 7 STATE FUND I] 8 STATE FUND S CHIEF FINANCIAL OFFICER LETTER (] 9 STATE FUND & CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM ] 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. IL � 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED 8 SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # m LOCATION CODE -OPTIONAL CENSUS TRACT N - 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 5ITE INFUKMA I IUN UNLT. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS \, FORM A (6-95)