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STATE OF CALIFORNIA :� ti 0 STATE WATER RESOURCES CONTROL BOARD W"9 � �; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , , ;c COMPLETE THIS FORM FOR EACH FACILITY/SITE °'��oew`' MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT Q 6 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) ORA ORFACILITYNAME NAME OF OPERATOR ESTA'lr QG A-/ V ADDRESS NEAREST CROSS STREET PARCEL a(OPFONAU ZCITYZ':5'/00 !7 T� C3Z1-o yl- /Z— CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE A Po CA 9 .1 Box TOIN GTE O CORPORATION O INDNIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O STATEAGENCY' 0 FEDERALAGENCY' 05TPoCTS' N owner d UST is e pudic agency,mrrpl"Us Iolowing:narre d SupeMwr of d"lon,aeclbn,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR = p SERVATION I / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.•(oplarwll Er 3 FARM 6 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE Of ADDRESS INFORMATION 11 Vers /G�j E- c5'T' -7-#m,45 3 � eLt-;nJ MAILINGOR STREET ADDRESS ✓ box bidicab ED INDIVIDUAL ED LOCAL-AGENCY 0 STATE AGENCY B• Q CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME -O� STATE ZIP9 _ PHONE WITH AREA CODE CA III, TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION !//�� O�irf MAILING OR STREET ADDRESS ✓ Eos biMbale 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE 4MY L9. Q Q O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE _r q�l7j/ 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 ✓box bbaem O 1 SELF-INSURED Q 2 GUARANTEE 0 31NSURANCE 0 A SURETY BOND D 5 LETTEROFCREDIT 0 s EXEMPTION D m 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.❑ IL❑ IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNEp'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# or m F-FT-1 1111 -77r719.6 LOCATION CODE -OPTIONAL CENSUSTRACT0 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �1 3. 30 'SC;- THIS STHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FORMM417