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STATE OF CALIFORNIA �- STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA o 3 ud�� vu COMPLETE THIS FORM FOR EACH FACILITY/SITE - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE • -o ONE ITEM OF INFORMATION ❑ T PE Y CLOSED SITE ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME 9 ) NAME OF OPERATOR lick I1 ADDRESS / LL NEAREST CROSS STREET PARCELI(pPTINxAV.) . CITY NAME A r ST CA LP CODE IS TE PHONE F W TH AREA CODE ✓BOX O CORPORATION INDIVIDUAL O PARTNERSHIP O COINIY-AGENCY' Q STATE-AGENCY' TOIN Box O LOCAL-AGENCY 'Iox*rerd UST'sepub4 egnry,mnpkle lie folbwil.wmede DISTRICTS (] F®FRAC-AGENCY' g upe�nrol dwisbn,soca,ordke x ich opeRNS the UST TYPE OF BUSINESS N GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN !3 TANKS AT SITE i P.A I.D.0 Ilboprep 3 FARM ❑ 4 PROCESSOR O 5 OTHER O RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 04A AV/ 2ND Z�_ All e / f 2a NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE k WITH AREA C DE mp/v `ZC/ 2v - �z _ f114� oAllf II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFO) Lif NAME CARE OF ADDRESS INFORMATION Smrr MAILINGORSTRFET AODRJE$S / ] A ✓ bc'IOFua'.a OINDIVIDUAL E LOCAL-AGENCY = STATE-AGENCY CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITYNAME STATE ZIP CODE PHONE M WITH AREA CODE ( �� r 9g7 Or, III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER ^^ CARE OF ADDRESS INFORMATION MAILING OR STREET AD//D SS // ✓ EoxW hEirale IVIDUAL 0 LOCALAGENCY O STATE-AGENCY �Vf 1— O CORPORATION O PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY CITY N EES r O STATE ( ZIP I)t 3 PHONE M WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(916))3212-9669 it questions arise. TY(TK) HQ F4-F4-]- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Soxb idipp O 1 SELF-INSURED Q 2 GUARANTEE O 31NSURANCE =4 SURETYBOND D 5 LETrEROFCREDTT =6 EXEMPTION T STATE FUND OBSTATE FUNDd CHIEF FINANCIAL OFFICER LETTER OBSTATE FUIO&CERTIFICATE OF DEPOSIT O10 LOCAL GOVT.MECHANISM O BI OTHEP 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.❑ II.❑ 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 MONTWDAWYEAR Zk , hq LOCAL AGENCY USE ONLY COUNTY p JURISDICTION R FACILITY N m [oil 161W Ill LOCATION CODE -OPTIONAL CENSUS TRACT/ -OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL V THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE LINFORMATION bNkLy. OWNER MUST FILE THIS F( VITH THE LOCAL AGENCY IMPLEMENTING THE UNDERG VD STORAGE TANK REGULATIONS FORM A(695) �,