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• 0 6oVn r4 C STATE OF CALIFORNIA 'b STATE WATER RESOURCES CONTROL BOARD W mom' n S UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�•�^"'� MARK ONLY ❑ f NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ITE ONE REM ❑ 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 ADDRESS � / �- ��f � NEA ES CRQS�TET PARCELx(OPiIONAI) CITY NAME STATE /A`"�ZIP CODE ITE PHO E x WITH AREA CODE LoD� CA 2 2''�( �6g- L/E).6 ✓ BOX (]CORPORATION (] INDIVIDUAL PARTNERSHIP (] LOCAL AGENCY COUNTY-AGENCY' STATE-AGENCY' (] FEDERAL-AGENCY' TO INDICATE DISTRICTS' If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATDION IAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LA T,FIRST) �E� HONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Zr� i'�� 2�� 3f2$->�a6 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 7 II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STRE T ADDRESS ^ ✓ box lo indicate 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY Z / 7 �/f p � &L7� 0�Q� CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME / STATEZIP CODE SL:) ��#�WIREA COT -76 III. TANK OWNER INFORM TION•(MUST BE COMPLETED) NAME-QF OV e r fy� CARE OF ADDRESS INFORMATION MAILING OR ISTTRREET ADDRESS ✓ box to indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY Zl�7 f �(�1 723/-e Y CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATS ZIP CODE _ �H'O�E ri W H A5FA CODE / IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HO F4]4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIndicate = 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND = 5 LETTER OF CREDIT =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.❑ if. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY i` � �' COUNTY# JURISDICTION# LOCATION CODE -OPTIONAL CENSSUSJRACT OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS F \ FORMA(3/93) • • ��