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STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD �y.,� tl�; UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A 1 COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ I PERMANENTLY CLOSED. TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIUTY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CgpE SITE PHONE If WITH AREA CODE 04A4P0 CA —lJ Zr,C-> ✓BOX []CORPORATION Q INDMDUAL PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCYED STATE-AGENCY' = FEOERAL-AGENCY' TO INDICATE DISTRICTS Mo.r of UST k a pubk apeny.CMVMS Ne 1oko ;name d sWor&ord#'Vision,section or ffm oicA opereles 119 UST F INDIAN TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR ❑ RE EIRVATION #OF TA#IKS AT SITE E.P.A I.0.11(optimal) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS TJ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE Y WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION T# e 054"1,f.910m IPA6 7-1oma !AILING OR STREET ADDRESS ✓ bulaR We O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 7 -74/3,� AV95;�;>64 5l// D CORPORATION E-1 PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNEFJ CARE OF ADDRESS INFORMATION F. xIi6 A� ro�Ala,aT�CIt MAILING ORSTRE ADDRESS $IBostovdole Q #AMDUAL O LOCAL-AGENCY O STATE-AGENCY 77 2� CORPORATION O PARTNERSHIP (]COUNTY-AGENCY = FEDERAL AGENCY Cr;NAME Q STATEZIP CODEPHONE WITH AREA CODE IV. BOARD OF EQUALIZATION TUST -STORAGE FEE ACCOUNT NUMBER AY-Call(916)322.96691 questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓mwlo lrgicele I SELF-NSUREO O 2 GUARANTEE O 3INSURANCE =4 SURETYBOND O 5 LETTEROFCREDIT O 8 EXEMPTION O T STATE FUND Q 8 STATE RRO&CHIEF FINANCIAL OFFICER LETTER =9 STATE RIND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM E3 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.❑ 11. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED a SIGNATURE) TANK OWNERS TITLE DATE MONTHVDAWYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# T 471 LOCATION CODE -OPDONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL -71.2-ilqxv 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 FOR Tit THE LOCAL AGENCY IMPLEMENTING THE UNDERGR )STORAGE TANK REGULATIONS FORM A(8.95) �/ `!