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• 600- f f STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE -"'°""�, MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [__�'7 PERMANENTLY CLOSED 9 ITE ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAOR FACILITYNAME NAME OF OPERATOR I //— ( 1_,t ADDRESSNEAREST CROSS STREET PNICELs(OPTIONAL) CITU NAME STATE ZIP CODE� SITE PHONE#WITH AREA CODE LotCa CA gszJa— TOI/ Box INDICATE I�CORPORATION ❑a'IRDIVIDUAL O PARTNERSHIP O LO wcls�r COUMY-AGENCY' I�STATE-AGENCY' O FEDEML#GENCY' II mmr ol UST Is a public agency,cornplale the following:name of Supervisor of division,section,or office which operates the UST TOPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 6 ptl ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal)— O I RESERVATION lac ml I S -I 5--Z = 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS I t EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAM ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE f e 20 3 -�H NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CO7] DE 1� l U II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS V ✓Ooc bindksts C .INBIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY 11, )L � CORPORATION = PARTNERSHIP =COUNTY-AGENCY FEDERAL AGENCY CITU NAME V V STATE ZIP CODE PHONE x WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING ORSTREETADDRESS �--,�/ ✓ Eox CiMksb CITTDIYIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY AGENCY (] FEDERAL-AGENCY CIN NAMEL 4, STAI ZIP CO <—?f j� PHO' WITH AREA CODE 7 IV.BOARD OFF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)x3122-966619 if questions arise. 3LP J TY(TK) HQ 4 4• - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓No bind une t SELF-INSURED 0 2 GUARANTEE 3 INSURANCE E__14 SURETY BOND H 5 LET TER OF CREDIT Oirg—EXEMPTION Q Sg OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[ia II.E�' III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAM E(PRINTED B SIGNED) OWNER'STrLE DATE MONTWDAYNEAR \ 8 2L LOCAL AGENCV USE ONLY COUNTY# JURISDICTION# FACILITY#00-2032- i LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL o Z3 7- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMA Y. OWNER MUST FILE THIS FOflin THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FCR00 i FORM A(393)