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STATE OF CALIFORNIA �� t� STATE WATER RESOURCES CONTROL BOARD :�� a°r UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A :w , COMPLETE THIS FORM FOR EACH FACILITY/SITE 'a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J DBA OR FACILITY NAME NAME OF OPERATOR ADDRESSpp NEAREST CROSS STREET PARCEL#IOPTONAL) /Z-/ -5 l CITY NAME STATE ZIP COqE SITE PH NE#WITH ARM CODE GD a CA 9y! lid >,�333- 6lrzp ✓BOX Q CORPORATION D NDNIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNrY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS N owner of UST is a public apeny,mmpMe Ore blowing renes of supervisor of awNon,Wien or office whih operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION Q 2 DISTRIBUTOR ❑ RESEIRVINDIAN ATION #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM Q # PROCESSOR ❑ THER OR TRUST LANDS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME( T.FIRST) P NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE it A vq NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION iT- Or MAILING OR STREET®AAD�DRESS ✓ bwb MWa O INDMDUAL LOCAL-AGENCY 0 STATE-AGENCY D O0 3 p0 i�CORPORATION Q PARTNERSHIP NrY-AGENCY [] FEDERAL-AGENCY CITY NAME STATE ZIP CODE ONE#WITH AREA CODE G&A7 I eja III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Gi Dt'E_ MAILING OR STRESTT ADDRESS ✓ bo#Ioodleste = ROMDUAL �OCAL-AGENCY 0STATE-AGENCY OF,'s7 -,,,IJO O CORPORATION = PARTNERSHIP COUNTY-AGDKY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE e,DAOZy • /R/JA f-D IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED ✓box to h(I= 1 SELF-INSURED O 2 GUARANTEE O 3INSURANCE =#6uRErYBOND 0 5 LETIEROFCREDR 0 8 EXEAIPTDN =7 STATE FUND D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER ED 9 STATE RIND b CERTFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHDAWYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m0 71L_-KF LOCATION CODE -OPTIONAL CET j5T # -OPTIONAL S VOR-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. FORMA(6-95) OWNER MUST FILE THIS FORT 'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGR( 'STORAGE TANK REGULATIONS % ✓ *11104