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• 6oV- ♦r •�C STATEOFCALIFORWA 'i STATE WATER RESOURCES CONTROL BOARD W,,,�' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE ``aeon•" MARK ONLY O i NEW PERMIT F__j 3 RENEWAL PERMIT 0 S CHANCE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ORAOR FACILITY NP E NAMEOFOPERATOR 52-& E S ADDRESS NEARESTCROS STREET PARCEL#(OPTIONAL) !tea CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE /�D r CA `7�5rD ' BOX LOCAL-AGENCY TOINDICATE O CORPORATION O INDIVIDUAL PARTNERSHIPl� DISTRICTS' COUMWAGENCY• O STATE AGENCY' O FEDERAL-AGENCY' 'N owner of UST Is a public agency,complete the following:name of Supervisor of dNicbn.section.or of ice which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR R/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.9 fgNwnal) ON 3 FARM Q 4 PROCESSOR5 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME( AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 7] /L C GIG �Zr�13r58— / NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ` CAREOF ADDRESS INFORMATION / 4S /�.p MAILING OR STREET ADDRESS ✓ bot bindbme INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY .c-, 15 7-. --1 , QCORPORATION E:1 PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY CITY NAMESTA ZIP CODE _-HONE A WITH AREA CODE /ter -!<W III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER j CARE OF ADDRESS INFORMATION 17 dre— 4S MAILING OR STREET ADDRESS ✓ bot bindicals D INDIVIDUAL 71 LOCAL-AGENCY O STATE AGENCY E- S%' 'e%• Z CORPORATION O PARTNERSHIP D COUN Y-AGENCY O FEDERAL-AGENCY CI ME NASTATE ZIP C�ODDE'! PHONE#WITH AREA CODE 1-007- 64 917 3!�9-' s�7 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ F4-14--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓boa biMbab 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 5 LETTEROFCREDIT (]6 ExEMRTION 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. II.n III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'STFrE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILTTY# ( G T LOCATION CODE -OPTIONAL CEN SUS TRACT# -OPTIONAL S1PVISSOR-DISTRICT CODE -OPTpNAL �. �O THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF sk INFORmATibN ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(31931 0 0 FORea13AA7