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• • ncxe STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s - COMPLETE THIS FORM FOR EACH FACILITY/SITE In MARK ONLY ❑ 1 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 FA ILITY NAME NAME OF OPERATOR ADDRESS �• �t rJ. NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STACEA ZIP CODE SITE PHONE#WITH AREA CODE L 9 0 ✓ BOX O CORPORATION Q INDIVIDUAL O PARTNERSHIP C::)LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS 9 ownar of UST Is a public agency,complete the followng:name of supernsar of 6mmon,section or o#ma which operates Ne UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ REV IF INDIAN #OF TANKS ATS ITE E.P.A. I.D.#(optional) ATION ❑ 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAtE(LAST,FIRST) PH�ONE�#pWITH AREA 01DDE/` DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE . �✓l/. ?Jr�T acv ` 07Y3Ca NIGHTS: N E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Z_ JJ II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) NAME *4— /' CARE OF ADDRESS INFORMATION (r— �,pt MAILING OR STREET ADDRESS ✓ box to mQxale IVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY r CORPORATION 2n PARTNERSHIP I=COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW ERCARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtolyd t. 096DIVIDUAL =LOCAL-AGENCY C-1STATE-AGENCY 0&/ f- c>-q k gT� D CORPORATION Zj PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE G�i�— IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED I� I SELF-INSURED = 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT I]5 EXEMPTION "7 STATE FUND ✓box to ihhdcale O ESTATE FUND&CHIEF FINANCIAL OFFICER LETTER 09STATE FUND&CERTIFICATE OF DEPOSIT O 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: I.❑ it.96 IT.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHYDAY/YEAR LOCAL AGENCY USE ONLY COUNTY k JURISDICTION# FACILITY# Z03 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVIz�DISTRICTCODE -OPTIONAL � -7 �� ,f:>2- 7-3. 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 FOROM THE LOCAL AGENCY IMPLEMENTING THE UNDERGI&STORAGE TANK REGULATIONS FORM q(6.85)