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a STATE OFCALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH ILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR J 0%'v ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) sys� _�. _ffu��%,� w poi-�3-oy CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S G CA91"!5,210 ✓ eox TO INDICATE 0 CORPORATION O INDIVIDUAL 71 PARTNERSHIP LOCAL.AGENCY Q COUNTY-AGENCY DISTRICTS D STATE-AGENCY FEDERAL-AGENCY TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR I = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oPHana1) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR = 5 OTHER OR TRUSTLANDS EMERGENCY CONTACT PERS EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AgE D YS: NAME(LAST,FIRST) so., Y`l"YY- 1 � l av9-QY�-S'Sc.9 PHONE A WITH AREA CnnP NIGHTS: NAME(LAST,FIRS NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) I G 1 IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINUORSTREETADORES ✓ boxb Wkab INDIVxOUAL 0LOCAL-AGENCY STATE-AGENCY _ O CORPORATION 0 PARTNERSHIP [DCOUNTY.AGENCY E-1 FEDERAL-AGENCY CITY NAME I � STATc ZIP CODE PHONE#WITH AREf O"9E- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER A CARE O AgRE INFORMATION Coxbi MAILNGORSTREETADDRES I INDIVIDUAL O LOSTATE-AGENCY OO 0 CORPORATION 0 PARTNERSHIP CWUNITYAGENCY L-1 FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHONE i WITH AREA CODE 19 7� 0;L— &414 - 3D& / IV.BOARD OF E FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 n�J� V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ Eax bintlicale [7 I SELFINSURED E-1 2 GUARANTEE L] 3 INSURANCE L-I 4 SURETY BOND 5 LETTER OF CREDIT =6 EXEMPTION = W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II rs c e CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ U. 111. Lv THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTJDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# KJ AXR // LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL T7 / ;I 3" .3.2 3L, ou) a a THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12-BI) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS a' � FCRD33A-R6/