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STATE OFCAUFORNIA P 9 STATE WATER RESOURCES CONTROL BOARD s4 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A C•tl-OP M• COMPLETE THIS FORM FOR EACH FACILRYISITE 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 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 04/iA-15ETd Efiel°Y Teter ADDRESS - NEAREST CROSS STREET PARCEL#(OWIONAu 301 LOM q CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA CODE 40a CA IgSZ�lt� Box TOINDICATE D CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY STATE AGENCY FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = -/ IF INDIAN IS OF TANKS AT SITE E.P.A. 1.D.%(optional) RESERVATION 3 FARM 4 PROCESSOR 5 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 MnP NIGHTS: NAME(LAST.FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA Coop II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION E" G_r_� MAILING OR STREET ADDRESS ✓ box bindleale L-] INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY _ of 44>,4f 14 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE LOA G4 957t/o III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF%WNER r� y � CARE OF ADORE 3S INFORMATION MAILING OR STREET ADDRESS• ✓ bov 0inkale 0 INDIVIDUAL LOCAL-AGENCY STATE AGENCY _301 O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY CIN NAME STATEZIP CODE PHONE%WITH AREA CODE G04 ---7Su/a IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -n�—I--I—� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bax k iMicale l—] I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE E-1 4 SURETY BONG 5 LETTER OF CREDIT (]6 EXEMPTION 99 OTHER 71 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 APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY% JURISDICTION At FACILITY# LOCATIONCODE OPTIONAL ICENSUSTRACT% -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL OZ. 23.fo 3Zc 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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST O E TANK REGULATIONS FOR0033A R6