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.. STATE OF CALIFORNIA `� STATE WATER RESOURCES CONTROL BOARD 3�. 4 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� =° COMPLETE THIS FORM FOR EACH FACILITY/SITE re, e 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED \ MARK ONLY ❑ r7 ❑ r� ONE REM ❑ 2 INTERIM PERMIT Q 0 AMENDED PERMIT ❑ 6 TEMPORARY SfTE CLOSURE j % I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR F#CILITY NJIIME NAME OF OPE R H4"5nl &A L ADDRE55 NEAREST CROSS S7EST PARCEL e(0PRONAL) 4632 Al. 6, c Lr! l CITY NAME Cr �,/ ST CA ZIP C SITE PHON a WITH AREA CODS ✓ BOX a CORPORATION UQ UNMWAL p PARTNERSHIP O LOCAL-AGENCYp CCUNTY-AGENcY• p STATE-AGENCY• p FEFEDpEERAL-AG^_ENCY• TO INDICATE DISTRICTS 'Iav a UST e a pabla agmry,mlpbN eM Ickwng n dHnuehn Of G'LNM1,section m Oft whCh apMmthe UST TYPE OF BUSINESS ®/GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN •OF TANKS AT SITE P.A. I.D.A(m6anal) / Q J FARM Q d PROCESSOR Q S OTNEARESERVATION OR TRUST LANDS • oa ��D EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional GAYS: NAME(LAST,FIRST) ////__ , � PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 1--1e/ 1`e NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Uar� s MAILING OR STREET ✓ Owbi16� DMOUAL p LOCAL AGENCY p STATE AGENCY 5 p -AGENCY -AGENCYCORPORATION p PARTNERSHP p COUNTY L CITY NAME/ STAjE ZIP CODE'ZO PHONEN WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /`wLIT .CL NAME OF ✓ OVj9.`,ETADRESS CARE OF ADDR FORMATION MAIDNGORSTREE ^` bwbiidoU ®-mmouAL =1LOCAL-AGENCYpSTATEAGENCY CORPORATION p PApnemOW p('AIME/-AGENCY p RDERAL.AGENcY CITY NAME STATE DP CODE PHONE 9 WITH AREA CODE � —CLW 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 METHODS) USED ✓babii6ou 1 SELF-NSUREG p 2 GUARWTEE p 3 NSIRANCE p A SURETYBOM p 5 LETTER OF CREDIT Q s DIEMPTAN p T STATE RIND Q 8 STATE RRA&CHIEF FINANCIAL OFFICER LEITER p 9 STATE ROM&CERTIFICATE OF DEPOSIT p 10 LOCAL GOVT.MECHANISM p N OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless box I or HIS checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING, L❑ IL❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK AME(PRINTED G TANK OVMER'S TITLE DATnXE MONTH YDAYNEAR U —2;7, LOCAL AGENCY USE ONLY COUNTY R JURISDICTION Y FACILITY 8 val's m LOCATION CODE -OPTIONAL CENSUS TRACT a-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL - THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMrr APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST RLE THIS FOP' H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC' 'TORAGE TANK REGULATIONS FORMA(695) 1 \J