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` • `/ STATE OF CALIFORNIA *.111101 STATE WATER RESOURCES CONTROL BOARD i- UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� '" COMPLETE THIS FORM FOR EACH FACILITY/SITE <„„at MARK ONLY ❑ I NEW PERMIT F—I 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPEOATOR ADDR $/ NEAREJCRO��ET PARCELI(OPTIONAL) 3 (T( Iry/II G„G/ ODE ITE WITH REA CODE CITY NAME / , STATE CA Z762b� 2119 07 16'204✓ BOX Q CORPORATION —NDMAIAL O PARTNERSHIP O LOM-AGENCY O COUIM-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS aormerof USTbaNbFca5eny,mnq iemete iV.ramsdsm rAsorMOrvism,swp orolreew itli*emlm6a NIST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ REIF INDIAN If OF TANKS AT SITE E P.A I.D.•(OWimMq `' 0 3 FARM Q a PROCESSOR 5 OTHER OR TRUST LANDS 0776 0 0A :22q 9 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D YS: NAME(LAST,FIR T) ' PHONE;WITH AW BODE DAYS: NAME(LAST,FIRST) PHONE 1 WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE a VATH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE F WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• a��• ✓ basbil6rau RIDMDUAL OLOCk-AGENCY ESTATE-AGENCY 2 `org— �`JLC Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE. 21P CODE A P� I AREA �G � Z5 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) LL// V I/F� NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa to ilGoll Q NDMWAL LOCAL-AGENCY STATE-AGENCY Q CORPORATIDN O PARTNERSHIP Q COUNTY-AGENCY a FEDERAL-AGENCY CRY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCpUNT NUMBER-Call(916)322.9669 it questions arise. TY(TK) HQ 4 4- /Vt- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Dmkitlkan ED I SELF-NSUREO 2 GUARANTEE O 3 INSURANCE ED e SURETY BOND Q 5 LETTEROFCREDIT I]6 EXEMPTION CD T STATE FUND O8STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE FUND&CERTIFICATE OFDEPOSIT 010 LOCAL GOVT.MECHANISM = 69 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O I N.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME D&SIGNA E) 1 TANK OWNER'S TITLE DATE MONTWDAY'NEAR d� -,�-q LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY A m LOCATION CODE -OPTIONAL I 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)