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JJw ,s STATE OF CALIFORNIA • s STATE WATER RESOURCES CONTROL BOARD 3�: �o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�; COMPLETE THIS FORM FOR EACH FACILITYISITE ��OwM,� MARK ONLY ❑ 3 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAM _zy IF NAMEOFOPERATOR Cr' 5.0 fa L G.), ADDRESS NEAREST CROSS STREET PARCEL#IOPTIONAL) ZUl/ 2 Lam_ sum CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE r�EA� CA 1Box s Z�� TOINDICATE E7 CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNrY-AGENCY [] STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 3 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x r pIA,,U RESERVATION Q 3 FARM O 4 PROCESSOR 5 OTHER OR TflUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•OP110nal DAYS: NAME(LAST.FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NA (LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS 9 WITH AREA rnpr II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS JT� J ✓box biMkaU INDIVIDUAL EI LOCAL.AGENCY LI STATE AGENCY CORPORATION 0 PARTNERSHIP COUNTY.AGENCY 0 FEDERAL.AGENCY CITY NAME STATEsLZIP CODE PHONE#WITH AREA CODE a tc 4 ,.� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• ✓ boa WW4ala E] INDIVIDUAL O LOCAL-AGENCY t]STATE-AGENCY Q CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY E�] FEDERAL-AGENCY CITY NAME STATE ZIP GODS PHONE#WITH AREA CODE IV. BOARD 0 EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO L4- Q V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa bh kale O i SELF INSURED 0 2 GUARANTEE [-13 INSURANCE E-1 4 SURETY SONO O 5 LETTEROFCREDIT = 6 EXEMPTION I—]N 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: 1.[�] II.[�] III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY 1 COUNTY# JURISDICTION# FACILITY# CN6�N 3� a k_ -- - - LOCATIONCODE OPTIONAL ICENSUS TRACT -OPTfOVAL SUPVISOR-DISTRICT CODE -OPTIONAL ; 00 THIS FORM MUST E ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS F o33