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STATE OF CALIFORNIA .• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A _1 �1pyT1 COMPLETE THIS FORM FOR EACH FACILITYISITE —mw MARK ONLY liv T NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONE REM F-12 INTERIM PERMIT E::] 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FA NAME OF OPERATOR en ADORES a NEAR STC OSSSTREET PARCEL#(OFRONAU c•J( 0,Q/ � r CITY NAME /D� STATE 21P E SITE PHONE a WITH AREA CODE V BOX TO DICVATE\ / I�LCORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' N owner of UST Is a public-agency,mrrplete the folowin :name of S DISTRICTS' g upervkor of dNbbn,eecibn,or office which operates the UST TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INVATIONDIAN -OF TANKS AT SITE E.P.A. L D.-(cpnmaU) 3 FARM 4 PROCESSOR 5 ORESERTHER OR TRUST LANDS p2— EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE-WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE to 541-*7d E NIGHTS: N (LAS , STS PHONE- ITHARO CODE NIGHTS: NAME(LAST, #RST) PHONE#'WITHAREACODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME /-- T, D CARE OF ADDRESS IN ORMATION Al C t a h-f MAILING ORSTREET ADDRESS ✓ DMIDMICAN, INDIVIDUAL L #GEN 0 STATE#GENCY .3C) rJeG� 0 3 1 V d. l�CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY N ME STATE ZIP CODE PHONE-WITH AREA CODE G2 C 5 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) `—XT Jo�f�7 NAMEOFO<W�N]ER�� CARE OF ADDRESS INFORMATION CEQ� MAILING OR STREET ADDRESS ✓ box bindbab ff INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE-WITH AREA CODE IV.BOARD OF EQUALIZATION 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 ✓ box badicats 0 1 SELF-INSURED [-]2 GUARANTEE E--1 S INSURANCE O 5 LETTER OF CREDIT O O W OTHER 6 EXEMPTION 0#SURETY BONG 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 SE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 IL vn� III.Q THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED B SIGNED) OWNER'STITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# _ IF 'I LOCATION CODE -OPTIONAL CENSUS IRACT- -OiPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FOAM A(30) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS -�� 10��0 b