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.. •.. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i dam, o°o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .n COMPLETE THIS FORM FOR EACH FACILITYISITE ;,n MARK ONLY � I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q B TEMPORARY SITE CLOSURE G I I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIUTY NAME NAME OF OPERATOR ADD SS NEAREST CROSS STREET PARCEL#(OPTIONAL) y4W �. sA .l CITYNAAAOEQ STATE ZIP CC2PE SITE PHONE R WITH AREA CODE CA ✓BOX CORPORATION O INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY' D STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS '10 rof UST¢aNbkagency,wmpletethefolbwnq�ofsLipery rofdNLWbn,se oroffNewhichapeales Ne UST TYPE OF BUSINESS O I GAS STATION 0 2 DISTRIBUTOR O ✓IF INDIAN R OF TANKS AT SITE I E.P.A I.D.#(optimal) RESERVATION 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DA�YS/: NAME LAST.FIRST) PHON@ R WITH AREA C D GAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAMFE-a �0 CARE OF ADDRESS INFORMATION MAIIUrrNG�{ORRS ET ADDRESIS INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY 7-1 8`Y7 Q CORPORATION O PARTNERSHIP O COUNTY'-AGENCY O FEDERAL-AGENCY CITY NAME STAT ZIP COD PHONE#WITH AREA CODE Ga,Mi T � �/Z Ill. TANK OWNER INFORMATION -(MUST BE COMPLETED) NAME QE OWNEIT CARE OF ADDRESS INFORMATION #lGSPLArd—� MMUNG OR STREET AD ESS ^ JJ�///�� ✓ boalendicae � INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY 2/ �N / 4,4 wl4- /�+ O CORPORATION O PARTNERSHIP Q COIINTY-AGENCY O FEDERAL-AGENCY CITY NAME S09 ZIi� PHONE R WITH AREA CODE xov— `i �j IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ [-4—F4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Wx to ota"Ie = I SELF-WSURED = 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT [:�j 6 EXEMPTION E:j 7 STATE FUND O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GO FT.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 NOTIFICATIONS AND BILLING: I.O II.0 III.O i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAWYEAR LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R FACILITY R L�.� Q� � FL1ZZ/4 LOCATION CODE -OPTIONAL CENSU9'7�iAC1{r-OPTIONAL SUPVISOR-DISTRICT CODE -OP710NAL Z l/ .117 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 FORT 'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' I STORAGE TANK REGULATIONS FORM A(8-95) 11111100 "