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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD .,'c e o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE �'id - MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CO I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J DBA ORFACILITYNAME NAME OF OPERATOR G � ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 3o CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE AC26 CA �SZ�f� TO IND61 ICATE 0 CORPORATION I�INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' DISTRICTS #awnarol UST bepubrx:egenry,wmplele to following:Iwnedsupervisor d division,seMbn wo#Ne which oprmes me UST TYPEOFBUSINESS ❑ 1 GASSTATION O 2 DISTRIBUTOR ✓IFINDIAN #OFTANKSATSITE E.P.A I.D.#(Optbnail 3 FARM 4 PROCESSOR ❑ RESERVATION 1 ❑ ❑ OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME�� CARE OF ADDRESS INFORMATION ✓ / MAILING OR STREET ADDRESS /� ✓ box lo'vMxale Q INDIVIDUAL =LOCAL-AGENCY I�STATE-AGENCY 30/ �0� I�CORPORATION O PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATEZlg � PHONE p WITH AREA CODE Ar V4 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoi7cate QINDVDUAL QLOCAL-AGENCY STATEdGENCY 3 d Y L,v,-7A =CORPORATION = PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAM ^' STATE Z14 5 ` PHONE#WITH AREA CODE IV.BOARD OF -- OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER e-(Call(916))322-9669 if questions arise. TY(TK) HQ [4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to irx irate O 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION [!:)7 STATE FUND I� 6STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY#311 �-/� Z> I 6 -710 / 2.J ryf��f LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVI OR-DISTRICT CODE -OPTIONAL d Z3. 1D 27> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS