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` oM STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD* NDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A COMPLETE THIS FORM FOR EACH F YISITE 77 1 EW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN LY CLO ED SITE MARK ONLY u, ONE R ^-� EM u 2 INTERIM PERMIT O A AMENDED PERMIT O a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFO MATION& ADDRESS•(MUST BE COMPLETED) NAME OF OPERATOR DBA OR FACILITY NAME EST CROSS STREET PARCEL A(OFTONALI ADDRESS CITY NAME / 7 S• 54, I STATE ZIP CODE SITE PHONE s WITH AREA CODE CA I/ BOX I7 COR Tom+ INDIVIDUAL =PARTNERSMP DSR-AAGENCY COUNTYAGENCY []STATE-AGENCY (]FEDERAL-AGENCY TD INDICATE E.P.A. I.D.a fopliMeQ TYPE OF BUSINESS O T 2 S STATION DISTRIBUTOR ✓ IF INDIAN a OF LANKS AT SITE Q PESERVATION O 3 FARM O A PROCESSOR Q 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST.FIRST) PHONE+WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PH [ ITH AREAc II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED cAREOF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS ✓ la. bZ "w (]INDIVIDUAL =LOCAL-AGENCY O STATE-AGENCY Q CORPORATION Q PARTNERSHIP =COUNrYAGEWY Q FEDERAL-AGECY CITY NAME I STATE ZIP CODE PHONE I WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADORES ✓ bF�G (= INDIVIDUAL O LOCAL-AGENCY DSTATE-AGENCY I7 CORPORATION PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY CITY NAME I STATE I ZIP CODE PHONE WITH AREA CODE IV.BOARD OF EO ZATION UST STORAGE FEE A OUNT NUMBER•Call(916)323.9555 it questions arise. TY(TK) HO 4 4 3 Z Z Z V. PETROLEUM U NCIA IBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eoz oiMP+n Cj 1 SELF-INSURED V 2 GUARANTEE 3 INSURANCE i_J<SURETY BOND 5 LETTER OF CREOT 6 EXEMPTION CC 99 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. II. ILL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COU x JURISDICTION FACILITY III CrTyD�3 3 72QZi 3 1 E LOCATION CODE -OPTIONAL CENSUS TRA -OP@TIONAL ISUPVISOR-DISTRICT CODE -OPL CT• T G / I 0-v I D � ZTIONAIT THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO '!LY AS FORM A(S-91) /�/