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• • yW^ e STATE OF CALIFORNIA �� STATE WATER RESOURCES CONTROL BOARD + �0 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A n� COMPLETE THIS FORM FOR EACH FACILITYISITE �CQ V Oa M�- MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S1TE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITYNAM NAME OF OPERATOR 7lQ ADDRESS NEA EST CROSS EET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CO S TE PHONE#WITH AREA CODE 4047 CA `;�__ ,).` 2 6 TO DICATE O CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCALAGENCY COUNTY AGENCYSTATE AGENCY' `� FEDERAL-AGEWY' DISTRICTS' N owner d UST Is a public agency,mnplete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ */RESERVATION IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aptimal) ❑ 3 FARM 0 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS I I i EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAMEJ(LAST FIR E 9 WIAREA COQEE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE F� L�I1 f ST) gey ( ,7iJJ 71 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA GODEr NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME_ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS M ✓ box binEbm# I�YI,NDIVIDUAL E-1LOCALAGENCY I�STATE AGENCY ED CORPORATION LZJ PARTNERSHIP E-1 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STA ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 0indicate INDIVIDUAL 0 LOCAL AGENCY 0 STATEAGENCY Lv. G'vC-i�jlT 1 - ED CORPORATION = PARTNERSHIP 0 COUMKAGENCY E=) FEDERAL-AGENCY CITY NAME STA ZIP CODE PHONE#WITH AREA E Z�'13�Qr� IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box binkas 0 I SELF INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 5 LETTEROFCREDIT 7-16 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.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY#07 0 5 e 3 �ajyL LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTpALLL I b / "';z1 _ ZJ •19-) THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3N3) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMiB Fpq#1XM