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• • a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD ERGROUND STORAGE TANK PERMIT APPLICATION • FORM A ETE THIS FORM FOR EACH FAC (SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7gFEMAPAL LY CLOSE ONE ONLY ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) rADDRESS TY NAME NAME OF OPERATOR l�2 C!-e fc /M NAu P q NEAREST CROSS STREET O � ! u STATE ZIP CODWITH AREA CODE� Lr, -3�s-G CORPORATION (]INDIVIDUAL ]PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY l�Sl� FE➢EML-AGENCYDISTRI TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR TS IF INDIAN A OF TANKS AT SITE (cptlonal) ❑ ❑ / RESERVATION / Q 3 FARM 4 PROCESSOR /5 OTHER OR TRUST LANOB EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME I ST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) H II, PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME e Gr Q MAILING OR STREETADD ESS ✓ box biMkib ] INDIVIDUAL (]LOCAL-AGENCY STATE-AGENCY O 13 ox- 7V 7 CORPORATION ] PARTNERSHIP (]COUNTY-AGENCY ] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 5/V 0;ILjp's';I-0i III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER �+ CARE OF ADDRESS INFORMATION uC �� MAILING OR STREET ADDRESS ✓ Oaa blMGtiN ] INDIVIDUAL ] LOCAL-AGENCY �STATE-AGENCY CORPORATION ] PARTNERSHIP ] COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME I STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 ii questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Soc blMic]Ie ] I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 1]d SURETY BOND ] 5 LETTER OF CREDIT ]6 EXEMPTION ] 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 the CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III.❑ 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# VOL-cr 1 � _E LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL^ y- � 3 6l THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(5-91)