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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE m ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRES NEA EST CROSSSj�EE"� PARCEL#(OPTIONAL) <br /> C�CIyJ <br /> CITY NAME STATE ZIP COD SITE PHONE#WITH AREA CODE <br /> La�2 CA .g qy3- Z't <br /> ✓BOX ED CORPORATION O INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGFNCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8owaerof UST#apublicagenq,MfMIeethefollowing:nameofsupeMeorolderision,S ionoroNice0hopereteSNe UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYNAM LAST�,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR^ PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I ZGS E. ✓ box to'uldcale Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> e%o CA 2sl ZP-�) 95ls- z-C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFOVV IER n CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> C ✓ boxtond'iaale INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP E__1 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NHMESTA_T1 ZIP zq� HONE#WI�AREA CO�Axe r <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to iMkwa 0 1 SELF-INSURED El 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND ED 5 LETTEROFCREDIT = a EXEMPTION =7 STATE FUND <br /> Q 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER =9STATE R/ND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. 111,O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -02�?N CENSUS TRAT -OPTIONAL SUPVISOR- TRICT CODE -OPTIONAL LZ'j l� <br /> M- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS F(W THE LOCAL AGENCY IMPLEMENTING THE UNDERG#STORAGE TANK REGULATIONS <br />