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'EgCU-C.S C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME ��AG� c t �o NAME OF OPERATOR Jr1 �N t�✓�1 ADDRES`S7 NEAREST CROSS STREET PARCEL # (OPTIONAL) / /� 1►/ f STATE CITY NAME STATE ZIP C DE/, SITE PHONE # WITH AREA CODE CA l ✓ BOX CORPORATION 0 INDIVIDUAL PARTNERSHIP D LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 0 FEDERAL -AGENCY' TO INDICATE DISTRICTS ' it owner of UST is a public agency, complete the following name of supervisor of division, section or office which operates the UST TYPE OF BUSINESS "i GAS STATION 2 DISTRIBUTOR ✓RVATION IF INDIAN # OF TANKS AT SITE E.P.A. 1. D. # (optional) 3 FARM 4 PROCESSOR O 5 OTHER RESE T/ OR TRUST LANDS // t?`1 ? i I --t EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE S(JbtA 5A_%"P4-1 cSt Cft 3- 3 `�f 6 ✓ box to indicate 19VIDUAL 0 LOCAL -AGENCY Q STATE -AGENCY NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE CITY NAME STATE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME_ _ ` C I t� S(►� H CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 19VIDUAL 0 LOCAL -AGENCY Q STATE -AGENCY IJ J_ CORPORATION Q PARTNERSHIP (] COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE STATE ZIP CODE ,r r PHONE # WITH AREA CODE Ill TANK CIWNFR INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ,, ti MAILING OR STREET ADDRESS w On�� tel _, ✓ boxto indicate INDIVIDUAL CORPORATION ETPARTNERSHIP LOCAL -AGENCY STATE -AGENCY COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE ,r r PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ F4--[4--] - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION E�] 7 STATE FUND 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 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: 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 & SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY ## 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 5111E INFUHINA I IUN uNLT. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95)