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STATE OF CALIFORNIA ss STATE WATER RESOURCES CONTROL BOARD .` UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILrI'Y/SITE MARK ONLY DI NEW PERMIT ❑ 3 RENEWAL PERMITuX ONE ITEM IV2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANEN ❑ A AMENDED PERMIT SITE ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DB FA ILITY N NAMED ERAT C� A ESS ' //q � f n A/ � ST R05S S EFT PARCEL#(OPTIONAL) -- CITY NA �V ILi yL IP STATE ZODE ,I V BOXG.A SITE PHO x WN�S}U1�AqEA CO TO INDICATE [�CORPORATION 0 INDIVIDUAL O PARTNERSHIP l=LOCAL-AGENCY I / / �� TYPE OF BUSINESS DISTRICTS ED I=STATE-AGENCY (] FEDERAL-AGENCY [:] 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN x OF 3 FARM AN S AT SITE E.P.A. I.D.x(00ma ❑ ❑ A PROCESSOR O O ESRVATION q 5 OTHER RE OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRS EMERGENCY CONTACT PERSON (SECONDARY) PHONE x WITH AREA CODE ) OP7(OR61 DAYS: NAME(LAST,FIRSn NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) [I. PROPERTY OWNER INFORMATION•IIIUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindkale Q INDIVIDUAL [] LOCAL-AGENCY STATE AGENCY CITY NAMEsO CORPORATION RPORATION O PARTNERSHIP 0 COUNTY.AGENCV C] FEDERAL AGENCY ZIP CODE PHONE x WITH ggEA CODE — III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓ bax biMkale I INDIVIDUAL CITY NAME �]CORPORATION = LOCAL-AGENCY f]STATE-AGENCY D PARTNERSHIP Cc ED FEDEgALAGENCY STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14 L7- V. PETROLEUM UST FINANCIAL -��R��ESSP�RESPONSIBILITY (MUST BE COM ETED)—IDENTIFY THE METHODS) USED ✓ box P indicate I�� 1 SELFINSURED 5 LETTER Of CREDIT GUARANTEE 7 INSURANCE 6 EXEMPTION " 99 OTHER A SURETY FOND VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles ox I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.❑ IIL❑ THIS FORM HAS @EEN 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/DAViVEAR LOCAL AGENCY USE ONLY �COUNTY# JURISDICTION# -OP RON r - FACILITY# hfA� 33 �_LL� ELOCATION , ALE CENSUS TBA3 x NAL — Z [GfU j SUPVISOR- ISTq CT CODE -Op TIONAL T/Y THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOR B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONL FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR