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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD NDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED.S ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ,-11 DBA OR FACILITY NAME NAME OF OPERATOR /1�,n to ADDRESS NEAREST CROSS STREET PARCEL (OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA C DE CA CIO?—Llnl�7 ✓BO% CORPORATION a INDIVIDUAL [=1 PARTNERSHIP LOCAL-AGENCY D COUNTY-AGENCY' O STATE- Y' = FEDERAL-AGENCY' TO INDICATE DISTRICTS XovmerOUSTmapubrK agenq.m Ima the tolb ng:name of supervisor ol timsion,selitm woNbe"0 operates the UST TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.N(optional) Q 3 FARM O 4 PROCESSOR 5 OTHER OR RESERVATION TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(IAST,FIRST) ONE ITH AREA COD DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA ECODE1 -c-c�/J, Z X 813NIGHTS: NAME(LAST,FIRST) O TH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA L(_Gr1 , 2a9 - II. PROPERTY OWNER INFORMATION-(MUS BE COMPLETED) NAMECARE OF ADDRESS INFORMATION ud MAILING OR STREET ADDRESS ✓ boxft, rate Q INDIVIDUAL O LOCAL-AGENCY f� STATE- AGENCY / =CORPORATION O PARTNERSHIP COUNTY-AGENCY FEOERALAGENCY CITY NAME STATE ZIP COD PHONEp WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNGER'�,, CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRE�55/ ✓ Dov to 4Mi ale O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY �N CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY C FEDERAL AGENCY CI NAME � Q STATE Z � P NITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. JAL/O TY(TK) HQ F4-14--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓OOvbindrale11 SELF-INSURED = 2 GUARANTEE Q 3 INSURANCE O d SURETYBOND 5 LETTEROFCREDIT 0 6 EXEMPTION =7 STATE FUND L.IJa STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE FUND&CERTIFICATE OF DEPOSIT I= tO LOCAL GOVT.MECHANISM = 990THER 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.O ICK 111.O THIS FORM HAS BEEN COMPLETED UNDERYtNALTY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MON /DAY/YEAR .5ceT 7�7.T_ IyJ Z/ S' LOCAL AGENCY USE ONLY O t CODN JURISDICTION N �FACILITY M f0� j_lWly�/t 1-1tl 12 11 1 V LOCATION CODE -OPTIONAL CENSUS TRACT -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 FOR 'H THE LOCAL AGENCY IMPLEMENTING THE UNDERC 'STORAGE TANK REGULATIONS FORM A(6-95) L/