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. • M1 <46o VM < Ca STATE OF CALIFORNIA W �" STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A FONN� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CL ©TfE ONE ITEM [i] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMENAME OF OPERATOR &yr ,,j C_ PARCEL»(OPTIONAL) ADDRESS NEAREST CROSS STREET L C' 11-kCITY NAME STATE ZIP CODESITE PHONE#WITH AREA CODE n CA S AK ✓ BOXO INDIVIDUAL O PARTNERSHIP f0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY D FEDERAL TO INDICATE CORPORATION DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ❑ RE/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM 0 4 PROCESSOR -OTHER OR TRUST LANDS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST / PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) edtre�goiW Sr/ - 666 6 NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 71 NIGHTS: NAME(LAST,FIRST) -WITH AREA COD; II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION S✓yl MAILING OR STREET ADDRESS ✓box blMbale O INDIVIDUAL OLOCAL-AGENCY O STATE-AGENCY CORPORATION D PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE At WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING ORSTREETADDRESS ✓ box binObata 0 INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -Iyl` 1 L LL1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicale 0 1 SELF INSURED ID 2 GUARANTEE ID 3 INSURANCE 0 A SURETY 80N0 D S LETTEROFCREMT O&EXEMPTION O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECKONE 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 APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Lx/ Ur 7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTflICT CGDE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(5-91) FO 079A5