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a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A CM FOCOMPLETE THIS FORR EAC ACILITYISITE MARK ONLY ❑ 1 NEW PERMIT -73 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY E NAME OF OPERATOR ADDR `H NEAREST CROSS STREET PARCEL#(OPTIONAL) CITI NAME ,a STATE ZIP COD SITE PHONE%WITH AREACODE p/T—VaYL� CA FN(i/MV v BOX TO INDICATE CORPORATION 0 INDIVIDUAL E=1 PARTNERSHIP [__1 LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE-AGENCY FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN 14 OF TANKS AT SITE E.P.A. I.D.%(wrional) RESERVATION O 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE%WITH AREA CODE DAV S: NAME(LAST,FIRST) em - 3PHONE a WITH AREA rnnP NIGHTS: NAME(LIT, IRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE / r II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME /p,.,a� CARE OF ADDRESS INFORMATION VT AI UNG OR STREET ADDRESS I ✓box bmCbau [_1 INDIVIDUAL O LOCAL-AGENCY L�] STATE AGENCY a a 3ct O CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITU ME ZIP t PHONE%WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINGORS EET ADDRESS Eox binAkau E] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION Q PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME' - STATE ZIP CODE PHONE%WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ Lf 4�- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box binAkau F-1 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE D 4 SURETY BOND 5 LETTER OF CREDT 6 EXEMPTION 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.❑ II. Ill. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAVNEAR LOCAL AGENCY USE ONLY n COUNTY# JURISDICTION# �� FACILITY# Ll LOCATION CODE -ONA� ICENSUS TRA - IDNAL � , 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 INFORMATIO ONLY. FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS /// L _ 3_ � �� FOR0073AR6