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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAM�OF ERATOR Q� ADDRESS NEAREST CROSS STREET PARCEL 9(OP RONAL) CIN NAME �D T ST CA ZIITE�" �J0NE#WITH AREA O ✓BOX 0 CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY* O FEDER&AGENCY' TO IMIICATE DISTRICTS ' No of USTisapubkagvq, tb thefolowng mum ds Iwvisor ddivision,sw.tion wofte which DPemhwft UST TYPE OF BUSINESSO 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN M OF TANKS AT BITE E P.A I.D.R(optional) RESERVATION ❑ 3 FARM ❑ 0 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DASY. NAME(LAST,R T) PHONE#;T1 AR A CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE S NIGHTS: NAME((—JLASSTT,FIRST) PHONE#WWITTI AREA O DE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS INDIVIDUAL O LOCAL-AGENCY El STATE AGENCY 11,64 O / CORPORATION O PARTNERSHIP ED COUNTY-AGENCY ED FEDERAL-AGENCY CITY NAAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF O N R-�y CARE OF ADDRESS INFORMATION MAILING�sOR STREET ADDRESS �s ✓ ODs b YWicwa 0 NOMEN DUAL Q LOCAL-AGCY O STATE-AGENCY / / CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAMEST; LCODE`2- PHONE a WITH AREA CODE IV.B`OAARRDD^OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)33222--9669 it questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bDab iidula 0 1 SELF-NEURED 0 2 GUARANTEE Q 3 INSURANCE O A SURETYBOND Q 5 LETTEROFCREDIT O 9 EXEMPTIONO 7 STATE FUND 0 a STATE FUND&CHIEF RNANCIALOFRCERLETTER l=9 STATEFUND&CERTFICATEOFDEPOSIT 019 LOCALGOVT.MECHANISM ED 98OTHER 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. It.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS RUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTFUDAYIYEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a1 FACILITY#36+0 ` o /v 3A LOCATION CODE -OP77ONAL CF-{{g^Ua -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 RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(5.95)