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STATE OF C FORNIA STATE WATER RESOURCES CONTROL BOARD `^ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM COMPLETE THIS FORM FOR EACH FACILITY/SITE ��....yy��011 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE l ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) r4 1<-a DBA FACILITY NAM NAME ERATOR A15D REST S RE PARCEL[(OPTIONAL)// � ve, CITY NAME STATECOD HONE WITH AR CODE CA 11 BOX Q CORPORATION 0 INDIVIDUAL � PARTNERSHIP LOCAL-AGENCY Q COUNT'-AGENCY• O STATE-AGENCY (]' y• TO INDICATE X •NomiIrd USTiP aWb&agMn Y.mnVNl.beb8owin.n ols DISTRICT6 - g eperviwrdtlrvLvm,sedimlwdfice wfiiIh o0,,the UST TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN k OF TANKS AT SITE E R A I.D.N[optionao Q 3 FARM ❑ 4 PROCESSOR Q 5 OTHERRESERVATION r OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST, IRST) / N WI AR C DE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 3 NIG S: AME(LAST,FlRST) PHONE M WITH MEA CODE NIGHTS. NAME(LAST,FIRST) PHONE N W AR CODE A' If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAM CME OF ADDRESS INFORMATION MAILING R EETA DRESS ✓ b=ID iXtW0 0INDIVIDUAL 'LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NA 170pST E ZIP OD PHON N TH AR/EA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) FNAMF WNER /t CARE OF ADDRESS INFORMATION 7TT\ l�{ MAIL G -ETADD SS Lad I ✓ boa b iwwe 0 NDIVIDUAL (A LOCAL-AGENCY STATE-AGENCY y . (�CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME/ STATE. 7 [JFa1 F7HAREA�Op� IV.BOARD ZI OF tQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions ariisye7J-OyJ� TY(TK) HO 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓O4a V bScYe l� I SELF-INSURED O 2 GUARANTEE O 3 INSURANCE (3 4 SURETYBOND 0 5 LETTER OF CREDIT =6 EXEMPTION O T STATE FUND (� 8 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER O P STATE FUND&CERTIFICATE OF DEPOSIT KO LOCAL GOVT.MECHANISM = 99 DINEL 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: 1.❑ II.K III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANKOWNER'S NAME(PRINTED&SIGNATURE) TANKOWNER'STITLE DATE MONTHiDAWYEM 4O 1 ie^t / © •D •� LO AL AGENCY U E ONLY COUNTY 0 JURISDICTION M FACILITY A m LOCATION CODE -OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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)