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STATE OFCALIFORNIA �� 4 STATE WATER RESOURCES CONTROL BOARD W ems' UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) I�6 OBA OR FA AME A NAME OF OPERATOR ADDRESS NEAREST CRgS�S STREET PARCELII(OPTIINAL) LA—)C CITY NAMEA STATE ZI SITE PHONE i WITH AREA CODE (✓�4C CA Z� TOINLDUCRTE O CORPORATION 0 INDIVIDUAL O PARTNERS14P O LOCAL-AGENCY [23'VT3NTY.AGENCYO STATE AGENCY' =1 FEDEML-AGENCY' DISTRICTS' 'N owner d UST Is a pubic agency,complete the fonowing:name of SupeNRor of division,section,or oHire which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION E__] 2 DISTRIBUTOR RE'/ IF INAN SE RVADON 0 O TANKS AT SITE E.P.A. I.D.a Tnpthnal) F-13 FARM � 4 PROCESSOR 5 OTHER OR TRUST LANDS Z.- EMERGENCY CONTACT PERSON (PRIMARY) - EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS' NAME(LAST.FIAT) PHONE ZIT REA CODE DAYS: NAME(LAST,FIRST) PONE a WITH AREA CODE. NIGHTS:NAME(LAST.FIRST) PHO a WITH AREA CODE NIGHTS: NAME(LAS ,FIRST) P NE i WITH AREA CODE as II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMr,jCAr OF ADDRESS INFORMATgN ll' O LL Y LOGS MAILING OR STREE DRES'S- 1 oo ✓boxick ome INDIVIDUAL Q LOCAL�AGENCY O STATE W� -(v O CORPORATION O PARTNERSHIP COUNTYAGENCY O FEDERALAGENCY CITU NAM TATE ZIP CODE PHONE ITH ARE CODE s � � - III. TANK OWNER INFORMATION-(MUST BE COMPLETED) FOWNER C OEOF ADDRESS INFO ATNDN I ct, Jt MAILING lOOR STREE ADDRESS ✓ wxbhb m � INDIVIDUAL (] LOCAL O STATE AGENCY P -- PX ax-e- CORPORATION O PARTNERSHIP COUNTYAGENCY = FEDERALAGENCY CITY 9 ZIP CODE I PHONE a WITH AREA DE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it question arise. TY(TK) HQ [4T4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bar bYWeeN 1 SELF.INSURED (]2 GUARANTEE ED 3 INSURANCE [-14 SURETY BOND D 5 LETTER OF CREDIT Q 5 EXEMPTION =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.❑ II.� III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'SNAME(PRINTED&SIGNED) OWNER'S TRLE DATE MONTH/DAY/YEA LOCAL AGENCY USE ONLY COUNTY a JURISDICTION It FACILITY• m Ig2J 51111-ETD] LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR- STR DIICT OODE -OPTTONN. d , 4, /y h4, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SIT1111,611PNIkATIOIN ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGLLLATIONS FORM A(393) FOROMA41/