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STATE OF CALIFORNIA o�; STATE WATER RESOURCES CONTROL BOARD 3.,� e; UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , ; I COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF CI NAME NAME OF OPERATOR AD RESS ,, J�� NEAREST CROSS STREET PARCEL lopITONAU �00 SO CRY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE GoJ CA v ✓BOX O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCM-AGENCY O COLNTY-AGENCY' O STATE-AGENCY' =FEDERAL-AGENCY' TO INDICATE DISTRICTS 9 owmruf USTI,epdSc alNex.Y,oyMjIge the fokwng re dsupervimrdtlMsion,sWionordficaxLidMretume UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN NOF TANKS AT SITE E.P.A. I.D.N(optional) RESERVATION / Q 3 FARM Q N PROCESSOR 5 OTHER OR TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D��E(_ .FIRST) PHO N WIT f1^CODEE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE v, 7J NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS �I .1boxMndcale O NDMWM AL I1 LOC -AGENCY 0 STATE AGENCY Z 1ZD Ai. Goa /SNV� O CORPORATION IED PARTNERSHIP =COUMY-AGENCY O FEDERAL-AGENCY CITY NAME STATEZIP CODE HONE N TH AREA COD,3 Goa N.� �/S c7 09 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEjOF WNER CARE OF ADDRESS INFORMATION MAILING ORS STREET ADDRESS ✓ buMNirAte 0 NDMDUAL [=j LOCAL-AGENCY O STATE.AGENCY Z/Ij;D - 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE P ONE tN�V1ITH AREA CODE v9J IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Dos Mei5u16 1 ssumfi IRED O 2 GUARANTEE O 3 INSURANCE O N SURETY BOND O 5 LETTER OFCREOR =6 EXEMPTION O T STATE FUND Q 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE RIND&CERTIFICATE OF DEPOSIT O 18 LOCAL GOVT.MECHMISM 1= 89 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. II.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N FACILITY N G- LOCATION CODE -OPTIONAL CENSUSTRAOTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL oz 23• � Z a THIS FORM MUST BE ACCOMPANIED BY ATLEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE 64FOWATION ONLY. OWNER MUST FILETHIS FOO TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR )3MRAGE TANK REGULATIONS FORM A(5-95) )✓/ `.(�