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STATE OF CALIFORNIA s *� STATE WATER RESOURCES CONTROL BOARD i�,� e a UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A 6p a COMPLETE THIS FORM FOR EACH FACILITYBITE MARK ONLY Q I NEW PERMIT F__j 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE ONE ITEM D 2 INTERIM PERMIT 0 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR lLv ADDRESS V't NEAREST CROSS STREET PARCEL#(OPTIONAL) ot7 5 aplbCo K�...E CRY NAME STATE ZIP CODE SITE PHONE R WITH AREA CODE t0151 CA q 15 Zyv ✓BOX 0 CORPORATION lj WDMDUAL ED PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' [::)FEDERAL-AGENCY' TO INDICATE DISTRICTS 'I aNTX01 USTIs aprm6c agercy.cmVleh WB IONOWN¢ =e of supervisor ol Qa6Lln,secion oroNce Mich Wmes BIB UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#Ioptlonaq RESERVATION Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS ' EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:OE(LA1,FlRBT) (�PHO�NE#WI2TH AREA CODE DAYS: NAME(LAST,FIRSn PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION W 2,Y 114AS0,1 MAILING OR STREET ADDRESS ✓ box 10n3rab E O INDIVIDUAL O LOCAL-AGENCY O STATE Z/1 zo / Oo= A t/�, ED CORPORATION 0 PARTNERSHIP Q COUNT'-AGENCY 0 FEDERAL-AGENCY CITYNAME STATE ZIP CODE PHONE 0 WITH AREA CODE GvD 04 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OFO NIR CA RE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Boslobdicale Q INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 7-1 Zo T AvC O CORPORATION = PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP COD PHONE WITH AREA CODE �15�D 5&1- —733 IV.BOARD OF 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 ✓Eoab irBrAt# O i SELF4NSURED O 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND =5 LETTEROFCREDIT O 8 EXEMPTION O 7 STATE FUND 08STATE FIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III.Q 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# JURISDICTION# FACILITY LOCATION CODE -OPTIONAL CENSU �N�ONAL SUPV�R-DISTRICT CODE -OP77ONAL o, 12 THIS FOCCRMM 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 FOR tH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR' T STORAGE TANK REGULATIONS FORM A(6-95)