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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3,,,� e; UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A :r ,d COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DEIOR FLac u C /LCL �TT�fI NA&aE Cf ERS 0�143uwc •I ADDRREESS�d NEAAJJREE1S�syCROSS L/STBEfjT, PARCEL a(OPTIONAL) & j%6 ( lLt �L 1 Le, ��tW it �PPdd1 CITY E STATE ZIP CODE ITE PHONE N WITH AREA CODE 'it twil CA r ?cs+�)83g-?yoz_ ✓BOX ED CORPORATION INDIVIDUAL E::] PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O SrATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS No o(LISTbap,lkap KY.OMVW ftbkwiV re ,I,Mervoora WN on,w6morofCmw itllW Waftu3T TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN it OF TANKS AT SITE I E.P.A 1.D.R(optional) RESERVATION 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 3 L1A-L dOO of 0 Z4 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D S: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE R WITH AREA CODE G TA,ei 4�D�nit ('L04 SS �1 D NIGHTS: NAME(LAST.FIR T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME 014 1 ,e We( CARE OF ADDRESS INFORMATION MAWnNGaN�OR STREIM1E/(yA`A,yDq/KESS ✓ bo[b Mr�e NWDUAL LOCAL-AGENCY CD STATE-AGENCY (y�p lj,r L, O CORPORATION PARTNERSHIPO COUNTY-AGENCY O FEDERAL-AGENCY Cm NAME BTA ZIP CODE P ONE a WITH AREA CODE 95'32D (?.m3 `623—?�i0 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM OF WNER CARE OF ADDRESS INFORMATION MAILING OR STREEIIADpRESS ✓ bula ndi®le NDIVIDUAL LOCAL-AGENCY STATE-AGENCY ?10/ l—v II 1=1 CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY DERALLAGENCY Cm NAME( BT6TE ZIP CODE 'C7 P 40NE If WITH AREA CODE 55�"l/� �UTA l/O/T� CLV C O l IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 i1 questions arise. TY(TK) HQ F4—T4--]- V. 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Iaeb irtlkale 1 SHFINSURED E.2 GUARANTEE I1 3INSURANCE 0 4 SURETY BOND O 5 LETTER OFCREDIT O 6 EXEMPTION O T STATE FUND �6STATE RIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT O10 LOCAL GOVT.MECHANISM O99 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 RESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.1$4 III.❑ THIS FORM HAS BEEN COMPL D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT T 14AMEEI(PRINTED& A , TANK OWNER'S DATE MONTHAOAYN R LOCAL AGENCY USE ONLY1-b c3l,3 COUNTY k JURISDICTION It FACILITY* IT-7 1013121,50131 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 FORY -H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROY STORAGE TANK REGULATIONS FORM A(6-95)