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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ?yds, nye UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE �e - t,In o MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA Oe 5ACIUTY NAME A �f / NAME OF OPERATOR ADDR✓EIL1 � , lr/—.G I NEAREST CROSS STREET PARCEL If(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE I1 WITH AREA CODE D CA ✓ BOX (]CORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS I ownerol UST is a pubic agency,oomplete the lalcwmg name of supervisord d'wbcn,mien or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN N OF TANKS AT SITE E.P.A. I.D.0(optional) RESERVATON Q 3 FARM Q < PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION (RAILING OR STREET ADDRESS ✓ box to odoale Q INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE k WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoind ale INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE 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 to indicate 1 SEF-INSURED [--)2 GUARANTEE [:13 INSURANCE 0 A SURETYBONO 0 5 LETTEROFCREDIT 0 6 EXEMPTION 0 7 STATE FUND �8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 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 NOTIFICATTON5 AND BILLING: I.❑ it.❑ III.O 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) TANKOWNER'S TITLE DATE MONTHIDAWYEAR LOCAL AGENCY USE ONLY COUNTY k JURISDICTION I FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT M -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. FORMA(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS