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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �ydb UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <s - COMPLETE THIS FORM FOR EACH FACILITYISITE Id ' 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 F&WLIIY NAME NAME OF OPERATOR t Q ADD RES NEAREST FROSS STREET PARCEL#(OPTIONAL) t z A �G CITY NAME STATE IP CODE SITE PH NEX WITH AREACODE CA 9533 6 z3 - 3Z 3 ✓BOXCORPORATION 1 INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS M omerN UST6 a WbOcagency,=pMlebeblbwbg:reme of supeMsorul division,section oroHice which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESV IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(aplionaQ Q 3 FARM ' Q 4 PROCESSOR ]$mj,5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIR T) PHONE p WITH AREA CODE DAYS: NAM (LAST,FIRST) PHONE p WITH AREA CODE Z 3 4' NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: AMT, RST) PHONE 0 WITH AREA CODE At. - 93Z — II. PROPERTY OWNER IN 0 MATION-(MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION OG- MAILING OR STREET ADDRESS ✓ boxloborate Q INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY Za S BG CORPORATION PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) S NA ER CARE OF ADDRESS INFORMATION D � OR STREET ADDRESS ✓ box londirele D INDIVIDUAL (] LOCALAGENCY STATSAGENCY S G -AGENCY -AGENCY CORPORATION PARTNERSHIP COUNTY CITY NA STA ZIP CODE PHONE%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 METHODS) USED ✓baxbiMicala 1 SELF-INSURED = 2 GUARANTEE >9L3 INSURANCE =4 SURETY BOND =5 LETTEROFCREDIT =6 EXEMPTION JK7 STATE FUND O ESTATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT [=1 10 LOCAL GOVT.MECHANISM = 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: LX 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(PRINTEDB IATURE) TANK OWNER'S TITLE DATE MONTHYDAYNEAR Gregg Bixel ir. , Plant Operatio s LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# FACILITY N m LOCATION CODE -OPTIONAL CENSUS TRACT -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 FORM A IS 95)