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NiSL L STATE OF CALIFORNIA a�O', y STATE WATER RESOURCES CONTROL BOARD %ei�� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° _ , o' COMPLETE THIS FORM FOR EACH FACILITY/SITE le MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR LSGtil.,E ADDRESS NEAREST CFOSS STREET PARCEL N(OPTIONAL) // Nn21C.�iWY Ouep CITY NAME STATE ZIP CODE SITE PHONE#WITH AREACO �pA]� CA 9 Z -367— 8 ✓BOX 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' 0 FE ERAL-AGENCY' TO INDICATE DISTRICTS IN omerof UST W a public agucy,omplete Na 1011ming:name cl smemsor of division,a bn croNhe A,ich Operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN N OF TANKS AT SITE F PP�..s X I.D.#(Optional) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHO E#WITH AREA CODE A/71-E ryi Z� —/oa(� /�v£ G✓ Za5 367-^ og$ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PM NE#WITH AREA CODE 22%od—3y4` II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRES INFORMATION Y T T MAILING OR STRE ADDRESS ✓ thax to 81e INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY G p 0 CORPORATION =�PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Lso/ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION jQ4v/,Q {J-17— MAILING ORSTRE,T DDRESS ✓ bosto NMicate O INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY -�#j/ T(> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDEyz* RAL-AG CY CITY NAME STATE ZIP CODEPHONE# ITH AREA CODE 7yrZ tj�7—D IV.BOARD OF EQUALIZZA-TIIO-N1 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 ✓bos MiMicate D 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE 0 4 SURETYBOND O 5 LETTEROFCREDIT 0 5 EXEMPTIONO 7 STATEFUND O B STATE FUND 6 CHIEF FINANCIAL OFFICER LETrER 09 STATE FUND B CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM O99OTHFA 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: I.❑ II. III.❑ 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) TANK OWNER'S TITLE DATE MONTHYDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# FT-1 1610 17 1 �0 /8 s LOCATION CODE -OPTIONALCENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL o LS:� 4 D P 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 FOFOTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRI&STORAGE TANK REGULATIONS FORMA(693)