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0 � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A tl� COMPLETE THIS FORM FOR EACH FACILITY/SITE � In MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE A• I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 DBA OR FACILITY NA NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL a(OPTIONAL) 7— CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE ✓BOX I CORPORATION =INDIVIDUAL = PARTNERSHIP =LOCAL-AGENCY =COUNTY-AGENCY' =STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE / DISTRICTS ff owner of UST's a public agenry,cooviete the following name of supervisor of division,section or officer ich operates Ne UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN a OF TANKS AT SITE E.P.A. I.D.M(optional) ❑ 3 FARM ❑ d PROCESSOR RESERVATION 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: N E(LAST,FIRS P ONE a ITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE I�AzD9� ► -7 NIGHTS: NAME(LAST,FIRST) PHONE F WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME �ryjr (I-`AAS CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS Z-03= �a *I box to br§rale = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY Z I 'I+O 119• AVE.- =CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CITY NAMEGon T STATE ZICODE � PH NE p ITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW ER CARE OF ADDRESS INFORMATION NAM= iz`r Rd � MAILING OR STREET ADDRESS J ✓ box to ndirale = INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY Z_11,0 !0 W- Z,V. A✓E • =CORPORATION = PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE P ONE a WITH AREA CODE z v� X5 0 36�r--7 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 METHOD(S) USED ✓box Mivlcale = 1 SELF-INSURED =2 GUARANTEE =3INSURANCE =a SURETY BOND =5 LETTEROFCREDR =6 EXEMPTION O 7 STATEFUND =6 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND A CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM 0 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: 1.❑ it. -O� 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(PRINTED&SIGNATURE) TANK OWNER'STITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N FACILITY M LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL LD-< 37.0 THIS FORM MUST BE ACCOMPANIED BY ATOT(1)OR MORE PERMIT APPLICATION- FORM B,UNLE IS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK REGULATIONS