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OUR g STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D CA C ACNU. I-W ,E NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) -zn e- LoU t .� CITY INA,* A` WSTATE # ZIPTE PHONE#WITH AREA CODE ✓/ BDX ox eco CA S`-3 3 b ,,-- .. ;109 S�aS-3 Z TO INDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP E:;J a A LAGENCY O COUNTY AGENCY O STATE-AGENCY O REDERAL-AC ENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opllonap ❑ 3 FARM O 4 PROCESSOR I�-DTHER RESERVATION - V OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 71 --EUZE I WITH AREA Door II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION rv�.v,.S 110 M AILING C R STRE ET ADD FESS ✓ box blMlGle Q INDIVIDUAL ��Lp �j A4AGENCV O STATEAG NCY CITY NAME O > Z 5�CORPORATION CO= PARTNERSHIP COUNTY-AGENCY Q FEDERAL ENCY PHONE#WITH AREA CODE aV1 c S lr'S 3 3 b Zoq cQa3. 3 zZi�' 1 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION CWl MAILING OR STR ET ADDRESS ✓ box binEbale D INDIVIDUAL O LOCAL-AGENCY-=STATE-AGE CV CORPORATION Q PARTNERSHIP Q COUNrY-AGENCY I= FEDERAL# ENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L4T4_1-Q2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b imicale 0 I SELF-INSURED I=2 GUARANTEE 0 3 INSURANCE [-14 SURETY SIC ND I= 5 LETTER OF CREDIT O 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. 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 APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTHIDAV/VEAR LOCAL AGENCY USE ONLY COUNCT,Y# JURISDICTION_ tFACILITY T� c Z/ _ _ LOCATION CGDE -OPTIONAL )CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3z . Bo THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANTE INFORMATION ON FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANKS 0 0 FOR 3A R6 i