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STATE OF CALIFORNIA �`'•....' STATE WATER RESOURCES CONTROL BOARD d o o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE w in MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY+NAME NAME OF OPERATOR O ADDRESS NEAREST CROSS ET PARCEL#(OPTIONAL) 9z1va All. /-I w y � � p CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE �`. CA a Z 3i - 101 TO INDICATE 0 CORPORATION 0 INDIVIDUAL E3 P-RX7 PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' DISTRICTS '9 ownero(UST is a public agency,romplete thatollowng:name of SUPeMsord BNi*n,sedbn urof ice which operates the UST TYPE OF BUSINESS l�t GAS STATION 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A I.D.#(optional) L RESERVATION 3 FARM O # 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 CODE L, r �,AO, NIGHT : NAME(LAST,FIRST) PHONE#WITH AREArCODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAM.E�� / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS __ 11 ✓ box tonCrate E::] INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY / /V /� jQ#I'� E:1 CORPORATION E::] PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE 01149 Z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION r--t,& E MAILING OR STREET ADDRESS ✓ b0t0inexala Q INDIVIDUAL ED LOCAL-AGENCY 0 STATE-AGENCY /ii5g OM// O CORPORATION [:1 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP COler-7"ej DE PHONE#WITH AREA CODE l� Z7. IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-966 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to rbkate t SELF-INSURED Q 2 GUARANTEE 0 S INSURANCE [=1 A SURETYBOND I)5 LETTEROFCREDR 8 EXEMPTIONO 7 STATE FUND 0 B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM ED 990THER 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 TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANKOWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# FT v---L=7_L/ 16 .—L�LILI LOCATION CODE -OPTIONAL CENSUS TRACT# -OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL I-SZC7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FORf6' TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS -