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STATE OF CALIFORNIA /�Q ^`fid••••• °o STATE WATER RESOURCES CONTROL BOARD iy UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITErnrn ie MARK ONLY F-1I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN TC`/ CLOSWSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAq E NAME OF OPERATOR �LIC- ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIPCOO SITE PHONE#WITH AREA CODE cA 9,2% ✓ BOX O CORPORATION D INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY- TO INDICATE DISTRICTS I merot UST is a public agency.complete the following wne of superneord diivision,section or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplianaq RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR21 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional DAY AME(L, PH E#WIITTHH AREA C?ODsE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(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 S MAILING OR STREET ADDRESS ✓ box Wheicale Q INDIVIDUAL I1 LOCAL-AGENCY Q STATE-AGENCY Z /� �'�• //�� V` Q CORPORATION O PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE, ZIP CODE I Zf9 STH AREA CODE '��/G J�rG� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N=WR NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS`! ✓ box to Indicate INDIVIDUAL =1 LOCAL-AGENCY =1 STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONEWITH AREA CODE Gon/ cfL�d aq Sri- 7�3 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED ✓Oox to iMnale 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND =5 LETTEROFCREDIT =6 EXEMPTION 0 7 STATE FUND Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 8 STATE FUND&CERTIFICATE OF DEPOSIT = 18 LOCAL GOVT.MECHANISM O 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.❑ 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 MONTHVDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ETTI Ela$� 3 7/23� LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY ATT(1)OR MORE PERMIT APPLICATION- FORM B,UNLES THIS IS A CHANGE OF SITE INFORMATI N ONLY. FORMA(6-95) OWNER MUST FILE THIS FORjW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK REGULATIONS