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�y %W 1401011' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , COMPLETE THIS FORM FOR EACH F ILITYISITE `'�^�^"'•- MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSE ONE REM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED) OBAO FACIL NAME /I NAME OF OPERATOR 7ird v�wIV ADDRESS N TCROSS :ET PMCELII(ORN7NAU CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE CA 95 3i3-5556 1 ZV Box 6 60 TOINDICATE CORPORATION O INDIVIDUAL [::]PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY' ED STATE AGENCY' 8'FF))EAAL-NNENCV' DISTRICTS- 1 oener d UST Is a public agency,complete the following:rune of Supervisor of division.section.or office which operates the UST TYPE OF BUSINESS O T CM STATION Q 2 DISTRIBUTORO v' IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#(opriauS RESERVATION Q 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS EMERGENC CqNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D TI PHON R DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE �5- NIGH j,S:fJAME(LAST,FIRSPHO EA WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓lox bintlkaM E:1 INDIVIDUAL LOCAL-AGENCY I��g/T 1114GENCY .S/ :) , e . O CDRPORATKN! 0 PARTNERSHIP O COUNTY-AGENCY 1�rFEDEMLAGENCY CITY NCAME STATE ZIP?Zd3 - 9 57 PHONE#WITH AREA CODE U n III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION SC., MAILING OR STREET ADDRESS bos" "u"' INDIVIDUAL LOCAL AGENCY O STATE AGENCY I�COREORATN7N PARTNERSHIP COUNTYAGENCY Q FEOERALASENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ba bYdeLs 0 1 SELF-INSURED 11 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND O 5 LETTEROFCREOIT O s EXEMPTION Q 99 CTHER 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 GNE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL 0 IS.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# F3T&II _ J LOCATION CODE•OPTIONAL CENSUS TRACT -OPRONAL 9UPVISOft-DISTRICT CODE -(OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE PERMrr APPLICATION• FORM B,UNLESSTHIS IS ACHANGE OF SITE IFORMA✓TKNI ONLLYY:f OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS V�Y FORMA(1931 w�90