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STATE OF CALIFORNIA °.° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE 'tl MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME � 4 I — NAME OF OPERATOR bom P AFLfI ADD E 5el// NEAREST CROSS STREET PARCELR(oPTI Q CI NAME STATE ZI OD ^� SI EON # ITISO A{iF� OyS ✓BOX CORPORATION O INDMDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' D STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE y DISTRICTS N ownerof UST Is a publb agmy,mmiate the folbwnP re odsupervisorddNv bn,sectionoroNice Mchoperatesthe UST TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR = ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.M IbROo.1) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D : NAM (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#W AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NA,M /J / CARE OF ADDRESS INFORMATION re V#r U Lr MG OR STREETAD RE q ) 61boxloffdmte D INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY Ne 1 /(/ 6coRponAnON Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY NAM 4,0A L� 1 / STATE ZIP.CD PyONg#WITHAREA CODE Ill. TANK OWNER IN/FORMATION-(MUST BE COMPLETED) [7/ Y//// /J— N ME OF OWNER /_ CARE OF ADDRESS INFORMATION Ufe AILING OR STREET ADDRESS I' baxtoixfiralO Q INDIVIDUAL 0 LOCAL-AGENCY (] STATE-AGENCY CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CM AM Igm 6d lszAr ZIP & PH n W R -CODE Y �-s IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-[4--l-� Nlp V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND O 5 LETTEAOFCREDIT =6 EXEMPTION 7 STATEFUND D e STATE FUND&CHIEF FINANCIAL OFFICER LETTER =B STATE FUND B CERTIFICATE OF DEPOSIT O 10 LOCALGOYT.MECHPNISM O B 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.❑ it. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT T OWNE 'S NA E(P I IGNATURE) TANK OWNER'STITL.EDATE MONTHID YNEAR 41 LOCAL A ENCY USE ONLY d A/ Ael.171 0 s d COUNTY It JURISDICTION# FACILITY It 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(6.95)