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• STATE OF CALIFORNIA • s sc}i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <r - COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSF�S2ITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE !/ J I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) LITY NAME NAME OF OPERATOR DBA OR FACI �CI STS%E 0 ADDRESS ^//1NEAREST CROSS STREET PARCEL X(OPTIONALI A6o/ �%MG/ 5 CITY NAME STATE ZIP CODE SITE PHONE X WITH AREA CODE Goy cA 9S��a ✓ BOX CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS If ownerd UST is a publb 8981 WMI)Me the WO ng:nem dsgor, Mrd QMI Wm or offm which operates the UST TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optbnaQ ❑ ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR OTHER OR TRUST LANDS L� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) P ONE X WITH AREACODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE c-.Bai —� Z6t 3W —3��6 NIGHTS: NAME(LAST,FIRST) P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CE �6_ z35t> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS .1boatokkate INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY Go/ r r r O CORPORATION O PARTNERSHIP COUN -AGENCY O FEDERAL-AGENCY CITU NAME STATE ZIP CODE P ONE X IkITH AREA CODE Z4SCt III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION L i LIG. MAILING OR STREET ADDRESS ✓ CORPORATIboxtomION Q PARTNEINDIVIDURSHIP O COUNTY-AGENCY FEDERSTATE-AL-AGENCY Q t-1, — � � O CORPORAPON f� PARTNEflSHIP � COUNTY-AGENCY � FEDERAL-AGENCY CITY/NNAM``E _STATE ZIP CODE PHONE M WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-F4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to lMnate = 1 SELF-INSURED I=2 GUARANTEE [__13 INSURANCE O 4 SURETY BOND =5 IETTEROFCREDIT O S EXEMPTION O 7 STATE FUND 08STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT = 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: 1.❑ 11.❑ 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'S TITLE DATE MONTHrDAYNEAR LOCAL AGENCY USE ONLY COUNTY X JURISDICTION# FACILITY E-2-11tlqv 7 m 2 1 LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL oZ Z3,Sv 3Z� sD 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 FOROH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS FORMA(6-95)