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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FORE H FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA RFACUTYMAM ,,•, - NAME OF OPERATOR ----------------------- RE / ZNE ESTCRROSS STR PARCEL 0(OFrIONAI) CITU NAM STATE ZIP( E�� S PHQNE#WI AREA CODE ✓ BOX CA TOINDICATE ED CORPORATION Q INDIVIDUAL E�:] PARTNERSHIP (]LOCAL-AGENCY Q COUNrY-AGENCY 0 STATE-AGENCY D FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.ar(oytlpW) ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OORTTION TRUST LANDS EMERGENCYEMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonat DAYS:NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINGO-STREET ADDRESS ✓ borb Wbau Q INDIVIDUAL I= LOCAL AGENCY O STATE-AGENCY CITU NAME M CORPORATION Q PARTNERSHIP = COUNTYAGENCY 0 FEDERALAGENCY STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION• (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bl"Ca O INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY CORPORATION 7:] PARTNERSHIP I=COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE - - IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14R]- Z 2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ETED)—IDENTIFY THE METHOD(S) USED ✓ bmbindbts I SELF-INSURED (] UARANTEE 3 INSURANCE A SURETY BOND 5 LETTEfl OF CREgT 6 EXEMPTION Q 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.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTHIDAWVEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE NAL CENSUS TRA Tx -t7P SUPVISOR-DISTRICT CODE -OPTIONAL 3 Z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B1 UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91)