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[�yOJa [ STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W a� :° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , COMPLETE THIS FORM FOR EACH FACILITY/SITE °4�ooa+`' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SIT ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE &p I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMS, % NAME OF OPERATOR ADDRESS NEARESTCROSSSTREET PARCELIF(OPTIOW ,Z� a-3316v TCF III CI NAMEiv STpCA ZIPWFF C „zzv SITE PHONE WITH AREA CODE AeAA.1 BOX TO DICATE f^O/'I I1 CORPORATION I�INDIVIDUAL [--jPARTNERSHIP (] LOCAL-AGENCYDISTRICTS' 0 COUNTY-AGENCY' O STATEAGENCV' O FEDERAL-AGENCY' X owns d UST Is a pubic agency,mrrpllAe the idlowbmd g:nae Supervkor d division,section a office which operates the UST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR I❑ ✓ IF INDIAN i OF TATIKS AT SITE E.P.A. I.D.a(bat" I flESERVATION 0 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE 11. PROPERTY RWNER INFORMATION- MUST BECOMPLETED) �#kpiY G —owl _ CARE OF ADDRESS INFORMATION MAILING IOL2STRE ADDRESS rqQ•%-j- ✓ Xa binEbaa Q INpryIDUAL I� LOCAL-AGENCY STATE-AGENCY 77�/ �� SvIT76 G 1 O CORPORATION O PARTNERS19P COUNTYAGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE � ��Y� �5zr a Ill. TANK OWNER INFORMATION-(MUST BECOMPLETED) NAME FOVADDRESS CARE OF ADDRESS INFORMATION MAILING//OR /�� + ✓bM bbaCas Q INDIVIDUAL LOCAL-AGENCY I� STATE TMNCY y / �Yy /P G �CORPORATION I�PARTNERSHIP (� COUNTY-AGENCY I� FEDERAL-AGENCY CITYY E STp ZIP COPE PHONE i WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ENt bindkNa L-1 1 SELFINSURED (]2 GUARANTEE O 3 INSURANCE O X SURETY BOND E LETTER OF CflEOT =S EXEMPTION [--1 fN OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be send to the tank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.9 III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND ORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DAIS MONTWDAYHYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION FACILITYIt D r 29 & qp4l&d LOCATION CODE -OPTIONAL CENSUSTRACTi -OPTIONAL BUPVISOR-DISTRICT CODE -OPTIONAL CIO) 1z3,IV r 8.0M THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(393) ION OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORm33AAT