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a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM Q 2 INTERIM PERMIT p 4 AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE .6 I. FACILITYISITE INFORMATION dt ADDRESS-(MUST BE COMPLETED) DBAORFA(;I TL E NAMEOFOPERATOR r )5;41,474 1 ADDRESS NEAREST CROSS STREET PARCEL I(OPTIONAJ 1 373 1 Iw o63-/6o- 13 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Lan= CA 95 Z'10 TOI/BOX INMATE p CORPORATION p INDIVIDUAL p PARTNERSHIP p �T'ACCE NNCY p COUNTY-AGENCY• p STATE-AGENCY' p FEDERALAGFNCY• 'N owner oT UST Is a pubic agency.complete the following:name of Supervisor of dNiebn,section,or oNice which operates the UST TYPE OF BUSINESS p 1 GAR STATION 2 DISTRIBUTOR = R/IF INDIIAN ON a OF TANKS AT SITE E.P.A. I.D.a(,"kW 3 FARM p 4 PROCESSOR p 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional F S: NAME MST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE HTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME ILAST,FIRST) PHONE a WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING ORSTREET RESS ✓ 6Dx b V10bala p INDIVIDUAL p LOCALAGENCY p STATE-AGENCY 7 T...3 (.✓Y p CORPORATION p PARTNERSHIP p COUNTY-AGENCY p FEDERALAGENCY CITY NAME STATE ZIP PHONE a WITH AREA CODE Loo-*- C4- 9 z- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ,eF-��4 MAILING OR STREET IDDRESS (� ✓ box b WkNe p INDIVIDUAL p LOCALAGENCY p STATE-AGENCY p CORPORATION CD PARTNERSHIP p COUNTYAGENCY p FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Gocz_T c/Fi 9�'u�� IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓bm at MsScAs p t SELF-INSURED p B GUARANTEE O g INSURANCE p 4 SURETYBOND Ip 5 IETTEROFCRENT p a EXEMPTION p tq 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.O ILK III.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY 1 CMNW# JURISDICTMto FACILITY• 007J-I �7— LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SLIPVISOR-DISTRICT CODE -OPIp 7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORlIIATI6N OXY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3'93) FOROm7MA7