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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 9 UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT Q # AMENDED PERMIT F-1 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / !� /• ,� NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAMEO Y V' v STATEZIP CODE SITE PHONE#WITH AREA CODE A 5a ✓BOX Q CORPORATION (] INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' (] FEDERAL-AGENCY' TO INDICATE DISTRICTS I omeral USTis a public alMlKY,complete the blbwng mune o(supeMsorcl Wmm,wtion arotru A6 operates to UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION VIFINDIANI#OFTANKSATSITE E.P.A. L D.#(optjo Q Q 3 FARM Q a PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE Ii. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME ',S n J Kj. ezO ra CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS rG` v b°me^ e Q INDIVIDUAL LOCAL-AGENCY O STATE AGENCY Q CORPORATION O PARTNERSHIP a COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxto Mule ED INDNIOUAL O LOCAL-AGENCY ED STATE-AGENCY Q CORPORATION = PARTNERSHIP E:1 COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE B WITH AREA CODE IV. BOARD OF EQUALIZATION UST RAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO F4-[4--]- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ucx;o iniea;e O 1 SELF-INSURED O 2 GUARANTEE 1=3 INSURANCE 0/SURE1YBOND =s LEFTEROFCREDIT =9 EXEMPTION O T STATEFUND O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER (-19 STATE FUND B CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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.E] II.D III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N FACILITY M LOCATION CODE-OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR•DISTRICyGDOE -OPTIONAL 3 a,— ' 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)