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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 r!+ AA MARK ONLY NEW PERMIT 3 RENEWAL PERMIT F__]5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE f I CA1%II ITVICITC INGnIZMATInN R AnnRFSS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OP RATOR Ail NAV V1 (=N k ADDRESS .6 NEAREST CROSS STREET p -A L av t o PARCEL / (OPTIONAL) CITY NAME STATE ZIP C E SITE PHONE N WITH AREA CODE `f i2 n C-• CA 5 3 0- - 3 l ✓ BOX CORPORATION a INDIVIDUAL [ PARTNERSHIP LOCAL -AGENCY COUNTY-AGENCYSTATE-AGENCY' El FEDERAL -AGENCY' TO INDICATE DISTRICTS ' H owner of UST is a public agency, complete the following: name of supervisor d division, section or office which operates the UST TYPE OF BUSINESS [� GAS STATION a 2 DISTRIBUTOR 4 PROCESSOR 5 OTHER ✓ IF INDIAN RESERVATION OR TRUST LANDS # OF TANKS AT SITE E. P. A. I. D. M (optional) N - W 3 FARM a GeecarPmr,v rn?4TArT PFRSON IPRIMARYI EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE 0 WITH AREA CODE JI,)bt-s S �7 tJN- "I ad( -3 4f I6 NIGHTS: NAME (LAST, FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE 31,E + ") 6 iSYY ✓ box to indicate 0 INDIVIDUAL II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME - � � n � � � � ( CARE OF ADDRESS INFORMATION MAILING ORS STREET ADDRE'S'S[ j - ✓ box to indicate M DUAL OLOCAL-AGENCY ij STATE -AGENCY -7 / - \ % /� ., t l_ I. %� (�, CORPORATION PARTNERSHIP l� COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME v`J V , r `+ STATE ZIqS 0DF_ 0 -1 - NE M WITH AREA CODE i � L. C� 7(o g3 - 34LJ� III TANK OW&R INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS o ✓ box to indicate 0 INDIVIDUAL 0 LOCAL -AGENCY Q STATE -AGENCY J t,)- = CORPORATION PARTNERSHIP COUNTY -AGENCY = FEDERAL -AGENCY CITY NAME -- -Q STATE CA ZIP CODE rPHONE I C?S 3 -76 N WITH AREA CODE 0-S3 3- 3 `tl 6 IV. BOARD bF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 it questions arise. TY (TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate tSELF-INSURED 0 2 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND ED5 LETTER OF CREDIT ELI6 EXEMPTION ICJ7 STATE FUND = 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM 0 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 d SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M FACILITY # m LOCATION CODE - OPTIONAL CENSUS TRACT M -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 SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95)