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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD e I` r� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONE ITEM O 2 INTERIM PERMIT a AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) O b(-" DBA OR FA ITY NAM NAMEOF OPERATOR �- at�' 5 ADO NEARESTCROSS STREET PARCEL#(OPfDNAU CITYNAMESTACA ZIP CODE 3 PHONE i WITH AR =0E TO BOX �CORPORATION Q INDIVIDUAL O PARTNERSHIP LOCAUAGENCY ODUNTYAGENCY' O STATE-AGENC ' I�FEDERALAC#NCY' B owner d UST N e pudic agency,conplete the following:name of S DISTRICTS' uperviaord tlNkbn,section.DI RICT Which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR -/ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.t TopgvWj 0 3 FARM Q 6 PROCESSOR Q S OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonel DAYS: AME(LAST,FIRST) PHONE IF WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE i WITH AREA CODE amovt NIGHTS:NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED IY)Z,2-1 NA (1 �r CARE OF ADDRESS INF TK)N J /i '- MAIL NG R STR E AD ESS ✓ceiO INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY 0 CORPORATION PARTNERSHIP O COIRKY#GENOY Q FEDERAL.AGENCY CI ME �4TEn ZIP DE HONE#WI AREA r III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �L7/ NAMEOF WNER CAREOFADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindksu 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION D PARTNERSHIP O COUNTYAGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)322-9669 if questions arise. TY(TK) HQ [4 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED ✓ bor biMkaie I SELF INSURED 2 GUARANTEE 3 INSURANCE I�A SURETY BOND 5 LETTEROFCREDIT O 5 EXEMPTION (]w OTIEfl 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. III.= THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION t FACILITY S -�n 115 led L4 LOCATION CODE -OPTIONAL CENSUS TRACTS-OP SUPVISOR-DISTRICTCODE - 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 FORM WITH THE LOCAL AGENCY "I'M/PLyvTEr�MEN/-TICN�G THE UNDERGROUND lSaTOR—AG/E TANK R!EEGU .FQMAW�� J U�TW�NS NIT / /atj 6% e- V _ LE� SS k 157(&, ►U l� �� (/