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1# ♦e/ STATE OF CALIFORNIA `* s of STATE WATER RESOURCES CONTROL BOARD iy UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ® `° COMPLETE THIS FORM FOR EACH FACILITY/SITE m, MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOffl ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESSNEARESTNEAREST CROSS STREET PARCEL#(OPnONAL) 7-1O V/"e7 A40 CITY NAME STATE ZIP CODE 11 SITE PHONE#WITH AREA CODE CA , #SzyT.— ✓ BOX O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS Xoenarol USTisapub5caguay,oDrtglMamefokv g:none of suPerviaatd&Woo.section or olrce Mich opeiatw MUST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplbnap RESERVATION 0 3 FARM Q # PROCESSOR ❑ 5 OTHER OR TRUST LANDS L EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE z-ve'OX6c, CIco s6g7_2 NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /&:�"64 G/ /Llvave__" MAILING OR STREET ADD RE ✓ bosloicocate Q INDMWAL LOCAL-AGENCY a STATE-AGENCY p 4/^I CORPORATION = PARTNERSHIP Q OWMY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 04 / CA 52� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAWOWN CARE OF ADDRESS INFORMATION /�I G/�j /`9Do/ff MAILING OR STAR♦EET ADDR S //�J ��//�� ✓ boab nGesla NDMDUAL 0 LOCAL-AGENCY STATE-AGENCY ./ y/ (c—C1/V' > CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERA.-AGENCY CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE litao/ 04 95z—�4 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 N questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box MFau 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE El<SURETY BOND Q S LETTER OF CREDIT =6 EXEMPTION 7 STATE FUND OBSTATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = ioLock 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.❑ II.O III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY#W77SZ�.rr E= 1 z1e� �g7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL NZ Jz zy y7 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)