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STATE OF CAUFORNIA J•� eco`, STATE WATER RESOURCES CONTROL BOARD +e,� e UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ,, a COMPLETE THIS FORM FOR EACH FACILrrY1SITE MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E::] 7 PERMANENTLY CL SED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME 1 NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL•(OPTIONAL) 21 1 95v 4 C+c. CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE M o CA I CJ ZZ ✓BOX ED CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNT'-AGENCY' I1 STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE DISTRICTS '#aeTNr d UST is a Public egday,MWI MMe(0110Wp:name d supeMwr d&Wm,section«dfiw Mich apemes the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN N OF TANKS AT SITE E P.A. I.D.#(apfb ml) RESERVATION ❑ 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION TfSrE � Ac'�-r91E � -s MAILING OR STREET AD ESS ✓ bom if u e ED INDIVIDUAL D LOCAL-AGENC/ STATE-AGENCY —7 -7 :5 G Q CORPORATION =PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE S'ro 9 W o III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERCARE OF ADDRESS INFORMATION Td,� O d,4-T/'O MAILING OR STREETDDRESS ✓ bozlo LlSlle D NDMIDUAL D LOCAL AGENCY ❑STATE-AGENCY 7 /L�. E ATE G I CORPORATION O PARTNERSHIP COUNTY-AGENCY a FEDERAL-AGDICY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE �i'bGK"rT� 1 D IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 0 questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Ip.to lydaatel SELFINSURED O 2 GUARANTEE 0 3 MWIPANCE =4 SURETY BOND O 5 LETTEROFCREDIr 0 e EXEMPTION O T STATE FUND H e STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 19 LOCAL GOVT.MECHANISM � W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANKOWNERSTITLE DATE MONTtlDAYNEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N FACILITY#,907909 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 FORE -H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC 'STORAGE TANK REGULATIONS FORM A(6-95) \� ` 71/3/1t