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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD NIS„ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , .y COMPLETE THIS FORM FOR EACH FACILITY/SITE °•�„a„��^ MARK ONLY F__j 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION tR 7 PERMANENTLY CLOSED SITE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT E] B TEMPORARY SITE CLOSURE U I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR f Lacy G rrr�ii ADDRESS �i NEAREST CROSS STREET PARCELA(0 IDNAW CITY NAME !/ STATE ZIP CODE SITE PHONE i WITH AREA CODE CAV BOX 52D TOINDICATE O CORPORATION 0 INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY' O STATE-AGENCY' ED FEDERAL-AGENCY' If cone,of UST is a public DISTRICTS' p agency,complete the lollowing:name of Supervisor of tlNiabn,section,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORQ ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.i(aptioaery RESERVATION Q 3 FARM = 4 PROCESSOR 5 OTHER OR TRUST LAN Del I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CAREOF ADDRESII INFORMAT ION �J� MAILING OR STREE AD RETS box O LOCAL-AGENCY 0 STATE-AGENCY Yv =COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NA E STATEA ZIP CODI- PHONE 1'WITH AREA CODE `7 D III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OYjNER CAREOFADDRE INFORMATION r -- - eE , 5 �SzYb MAILING OR STREET DR SS�"I �a ✓ box bintlbaN INDIVIDUAL L—I LOCAL AGENCY =STATE-AGENCY `7� 0 CORPORATION PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F41 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boxblMkate O 1 SELF-INSURED [:D 2 GUARANTEE (]3 INSURANCE 0 4 SURETY BOND D 5 LETTEROFCREDIT =a EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III.= THIS FORM HAS BEEN COMPLETED UNDER PENALTY CLE PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAWYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# �FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACTi -OPTIONAL 9UPVISOfl-DISTRICT CODE -CPTx)NAL 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(393) FG3AlT OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ��