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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A .n� COMPLETE THIS FORM FOR EACH FACILITY/SITE `'x�•o•+" MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � 7 PERM /LY/CLOSED 51 ONE REM 0 2 INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE G L- I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) Ik DBA ORF CI TY NAME L� �1 '� NAME OF P RTO ADDRESS 7I'y L-1L NEAF143TOOM STREET PARCEL/(OPTIONAL) 3 3 CITY NAME y _ STATE ZIP DE 5 TE PHONE s WITH AREA LOCAL-AGENCY TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 DISTRICTS' CAUNIY,IGENCY' OSTATE-AGENCY' OFEDERAL-AGENCY' If owner of UST is a public agency,complete the lu6owlng:name of Supervisor of d"ion,section,or office which operates the UST O ✓ IF INDIAN s OF TANyIS AT SITE E.P.A. I.D.R(tpfimal) TYPE OF BUSINESS 0 I GAS STATION Q 2 DISTRIBUTOR RESERVATION /`)CS 0 3 FARM Q A PROCESSOR Q 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 Is WITH AREA CODE 7] NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME / A CARE OF ADDRESS INFORMA 10 oc I kt C , v MAILI RSTREETRESS box bulk°% lj INDIVIDUAL =1L AUAGENCY Q STATE AGENCY X0 CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY CiTV ST Z CO E��- PHONE s WITH AREA CODE S ren, III. TANK OWNER INFORMATION-(MUST BE COMPLETE Z NAME OF OWNER ^ I n CARE OF ADDRESS INFORMATION I'I MAILING OR STREET L\IORESS lX ( ✓ Ips 0im"m 0INDIVIDUAL O LOCAL AGENCY O STATE.A CY l)/✓� `�5�� =CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERALAG V CITY NAM 0. /) STATE ZIP CODE PHONE N WITH AREA CODE �, IJ-}a�r••l � 299- IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box lo Indicate CI I SELF INSURED (] 2 GUARANTEE C,I 3 INSURANCE a SURETY BOND O 5 LETTEROFCREDIT O 6 EXEMPTION O %OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is hacked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.v 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAYHEAR LOCAL AGENCY USE ONLY 59COUNTYJURISDICTION � N 1 ' FACILITY � I/�^ LOCATION COI1b TIONAL CENSUS TRtC :,yFT SUPVISOR-DISTRICT C09E - N,y ��I `LTJJI THIS FORM MUST BE ACCOMPANIED BY AT LEAST(A(11)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA WANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG yQ�' , FORMA(193) � � �/�� FORDTI