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fya4AclS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE ,, MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF iNFORMATTON 7 PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) DBAFACILITTTyyy NAME NAME OF OPERATOR �. I ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 7711 1 CITYN ME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA ✓BOXi CORPOR TION 0 INDIVIDUAL L) PARTNERSHIP LGCALaAGENCY COUNTY-AGENCY' STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS ' M owner o1 UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS t GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ,e I q16-q1_1 NIGHTS: NA (LA,S FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE fia II. PROPERTY OW ER INFORMATION-(MUST BE COMPLETED) NAME TV OF ADDRESS£NF R ATI ` 1. e.. ? mm MAI LINO OR STREET ADDRESS ✓ box to indicate 0 INONIDUAt LOCAL-AGENCY 0 STATE-AGENCY W200 CORFORATION L_j PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE / PHONE#WITH AREA CODE CA - � a III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NA OF OW CA OF ACQ ES FO ATION eil es MAI EING OR STREET ADDRESS ✓ box fo ndcata INDIVIDUAL LOCAL-AGENCY STATE-AGENCY Bux 9g INCORPORATION Q PARTNERSHIP D COUNTY-AGENCY [] FEDERAL-AGENCY CITY •ME S ZIP CODE PHONE#WITH AREA CODE 6� ,5 5 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)322-9669 if questions arise. TY(TK) HQ $ 4- -1 Q 13 111 jEER V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicateSELF-INSURED [ )2 GUARANTEE = 3 INSURANCE L�jl 4 SURETY BOND 7715 LETTER OF CREDIT Q 6 EXEMPTION 0 7 STATE FUND E71 6 STATE FUNDS CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUNDS CERTIFICATE OF DEPOSIT © FO LOCAL GOVT.MECHANISM Q 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.[::] [I.D III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THF BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME{PRINTED&SIGNURE) TANK OWNERS TITLE DATE MONTHIDAYYEAR 17-7 " LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# M10 103l� LOCATION CODE -OPTIONAL CENSUS TRACT# •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 FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS FORM A(6-95)