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a STATE OF CALIFORNIA v �� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE RE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT IXI 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑4 6 TEMPORARY SITE CLOSURE �— I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME I NAI OF OPERATO 7 ho s 'S vim L D ADDRESS NEAR TCROSS FEET PA Y(OPTIONAL) CIN NAM - STATE ZIP CODE S191, ITE PHONE X WITH AREA CODE ✓BOX CORPORATION O INDIVIDUAL O PARTNERSHIP QLOCAL-AGENCY O COUNTY-AGENCY' I0 S ATE-AGENCY' O FEDERAL-AGENCY' T)INDICATE DISTRICTS I owwerol UST is a public agency,complete the lalbwing=ad supervisord Gnispn,section orrice which opocces the UST F INDTYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESETIVATION #OF TANKS AT SITE E.P.A I.D.M(optionaq Q 3 FARM O 4 PROCESSOR O S 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 a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION gaj MAILING OR S7` ADDRESS .� ✓ box to ul7wale O INDIVIDUAL O LOCAL-AGENCY OSTATE-AGENCY S ORPORATWN O PARTNE SHIP O COUNTY-AGENCY ED FEDERAL-AGENCY TAT ZIP CODE yy P ONE# ITHAREACOD CITY N E Cl S D D' III. TANK OWNER INFORMATION-(MUS BE COMPLETED) WWW NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoW ate Q INDIVIDUAL E3 LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION O PARTNERSHIP a COUNIY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4]-4-]- V. 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box he mime 1 SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND f�5 LETTER OF CREDIT Q 6 EXEMPTION �T STATE FUND K 3 STATE FIND&CHIEF FINANCIAL OFFICER LETTER Q S STATE FUND&CERTIFICATEOF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 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.❑ 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY . CTOUNTY# J(URISD�ICTION# FACILITY It b LOCATION COD _OPIONAL CENSUS TRACTjOWL- L SUPVISOR-DISTRICT CODE -OPTI L / THIS FORM MUST BE ACCOMPANIED BY AT LEA/AST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIJj�D STORAGE TANK REGULATIONS FORM A(6.95)