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..ai STATE OF CALIFORNIA .'•• o� STATE WATER RESOURCES CONTROL BOARD +eM®� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :p COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT —XI, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACIUTY ME NAME OF PERATOR xaev ADDRn ,6 NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAMESTATE ZIP CODE SITE PHONE N WITH AREA CODE �yG, CA W,BOX I_I CORPORATION [X#IDNIDUAL ED PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY' O STATE-AGENCY' D FEDERAL-AGENCY' TO INDICATE DISTRICTS Nonnrtl UST is apubk III oNrgMM the N1104hIt rwm d supervuorof tlNMMn,Mellon oro0ke"ich openees the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 RESEIRVA¶AONN M OF TANKS AT SITE E P.A I.D.N(optional) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS' NAME(LAST,FIRST) PHONE M ITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11 If. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION #j J} SAN MAILINGOR STREETAODRESAIL�I ✓ ksU e INDIVIDUAL C::] LOCAL-AGENCY O STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODEPHONE# ITH AREA CODE �Zb III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box W irdmis 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE IV.BOARD OF EQUALIZ A T ION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HO F4-F4 - Lt1 L17��e V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bar to irdicale ED 1 SELF-INSURED F—)2 GUARANTEE [::] 3 INSURANCE 0 4 SURETY BOND [__1 5 LETTEROFCREDIr Q&EXEMPRL-17 STATERIND 0#STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM N 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11. III.❑ 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 MONTHNAYNEAR LOCAL AGENCY USE ONLY TD COUNTY# JURISDICTION# FACILITY# LOCATION COD -OPTIONAL CENSUS TFIACTN -OPTI AL BUPVIBOR-DISTRICT C E -OPTIONAL CQ 3 L �fr�J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(6-95) „/� OWNER MUST CL AGENCY NG THE UNDE� STORAGE TANK CATIONS — Q ' c- , /S TSI '/� .