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STATE OF CALIFORNIA W e i STATE WATER RESOURCES CONTROL BOARD 3 e,� _ m 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A n _ ,- COMPLETE THIS FORM FOR EACH FACILITYISITE m MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT _] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIL NAME /' NAME OF OPERATOR /� TL G{ii's�/rl � ✓ (r ADDRESS NEAREST C�R�OS`S STREETPARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Goon CA ?sZ� ✓BOX D CORPORATION D INDIVIDUAL D PARTNERSHIP D LOGAL-AGENCY D COUNTY-AGENCY' D STATE-AGENCY' D FEDERAL-AGENCY' TO INDICATEDISTRICTS '9ownerol USTis a public agency,mmplete the following:name of supervisor of division,section oroffice whirh operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR O RE EIRVATIION AN #OF TANKS AT SITE E.P.A. I.D.#(optima ❑ 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS 0 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE ,3�1Ty W. �ti. �2uSj i — 07Zs5 NIGHTS: ry4ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME ,/ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxWmdcate D INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY ty/ C ST, D CORPORATION D PARTNERSHIP D COUNT'-AGENCY D FEDERAUAGENCY CITY e'.5"NAME n/ STATE ZIP057—ODE PHONE#WITH AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) �� 5� NAME OF OWNER 1 CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtondicate D INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY ZC?/ C% D CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE 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 M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box 1p ir6=111 I� 1 SELF-INSURED D 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND =5 LETTEROFCRE01r 0 6 EXEMPTION 0 7 STATE FUND D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER D 9 STATE FUND&CERTIFICATEOF DEPOSIT E-1 18 LOCAL GOVT.MECHANISM O 990TNEP 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 TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH7DAWYEAR LOCAL AGENCY USE ONLY COUNTY Is JURISDICTION# FACILITY It T LOCATION CODE-OPTIONAL CENSUS TRACT# .OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL C — 7r. 7T7 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 FORIO THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS FORMA(6-95)