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• ssounee STATE OF CALIFORNIA e�`; STATE WATER RESOURCES CONTROL BOARD n',;,� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o ACOMPLETETHIS FORM FOR EACH FACILITYISITE MARK ONLY O I NEW PERMIT 3 RENEWAL PERMIT LD 5 CHANGE OF INFORMATION L] 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6' I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAC% IT�.N�AME,�_ NAME OF OPERATOR / ^' -.— ADDRESS NEAREST CROSS STREET PARCEL#(OPfIONAL) �a dao c ,5/c�y iz CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE G,ap r/^ CA f� TO INDICATE CORPORATION O INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY COUNTKAGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RES IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.S(oplimal) 3 FARM 4 PROCESSOR �15 MER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) RHONE*WITH ARTA rn:DF: NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA COTIP If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME pp� )/' CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS �•• pIT Aja ✓box blMka L-1INDIVIDUAL0 LOCAL-AGENCY Q STATE-AGENCY 3ZQ JD /YG�/ /�L cLY7/� =CORPORATION = PARTNERSHIP COUNTY-AGENCY 0FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAF CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS• �T�lli�rL fix+ rr 7 ✓ box biMicale INDIVIDUAL LOCALAGENCY (� STATE AGENCY O CORPORATION 0 PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME- i S�^ — ZIP CADEPHONE t WITH AREA CODE G(f- IV. BOARD OF EQUALIZATION USt STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO `' 14 � n V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ box bintlicale 1 SELF-INSURED 2 GUARANTEE [, fi INSURANCE L=1 4 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 checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.IF--] II.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTYY\# JURISDICTION# LOCATION CODE OPTION A` CENSUSTRACTN -OPTIONAL � l SUPVISOR-DISTRICT CODE -OPTIONAL 3Z,0 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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOROO66ARfi