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u� e _ ♦x� c STATE OF CALIFORNIA �� s, STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A i COMPLETE THIS FORM FOR EACH FACILITYISITE °�xi�oe•" MARK ONLY i NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE ONE REM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 7� ADDRESNEAREST CROSS STREET PARCEL 0(OPTIONAL) ZSz 1F - Go4s AvE CITY NAME STATE ZIP CODE "� SITE PHONE*WITH AREA CODE Le�&7- Ca Zz/D T 1NDICAX 0TE D CORPORATION [—I INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q cOUNTY-AaENCY' STATE.AGENCY' E:3 FEDERALAGENCY' DSTRICTS' N owner of UST is a public agency,complete the following:name of Supervisor of d"Jon,section.or office which operates the UST TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTORI qE/ IF IND OAN N A OF TANKS AT SITE E.P.A. I.D.*Itpflvup 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE B WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME tLAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINGOR STREET ADDRESS / ✓ boxiointlks4 INDIVIDUAL OLOCAL-AGENCY 0 STATE-AGENCY3 (]CORPORATION PARTNERSWP I�COUNTY AGENCY FIEDEIULAGENCY CITY//NAME�� STATE ZIP CODE PHONE 0 NTH AREA CODE (/L✓/J` C III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMED OWNER CARE OF ADDRESS INFORMATION Gz- LIL2PpF,�Y MAILING OR STREET ADDRESSr ✓box b irldkaM INDIVIDUAL O LOCAL-AGENCY /—oR0 ST- O STATE-ACENCY `i✓c� CORPORATION I� PARTNERSHIP COUMY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE �f, 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 ✓Dox fs NldeW O t SELF-INSURED Q 2 GUARANTEE Q]INSURANCE O 4 SURETY BOND I�5 LETTER OF CREDIT 6 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O Il.O 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 B SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY* - LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPT70NAL o Z3. ZL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A 1393) FOIMMA)