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i a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 1T UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AA� COMPLETE THIS FORM FOR EACH FACILRY/SITE MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT g TEMPORARY SITE CLOSURE 6a I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) U DBA OR F CILITY NAME NAME OF OPERATOR -• Ks-4� ADDRESS NEAREST CROSS SSTREET� PARCELN(OPfpNAL) CITY NAME? STATEA^A •ZT__Iy7P CAO- It o TE p NE i WITH A A CODDEEBOX t-. T Nq TE 0 CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY _ DISTRICTS STATE-AGENCY FEOEMLAGENCY TYPE OF BUSINESS F__1ATION F-12 DISTRIBUTOR ✓ IF INDIAN NOF TANKS AT SITE P.A. I.D.N(optional)RESERVATION 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) / WITH AREA C—E _ DAYS: NAME(LAST,FIRST) /YCZ 'b NIGHTS: NAME(L T,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) If. PROPERTY OWNEP INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓hot b STATE-AGENCY CORPORATION � INDIVIDUAL EDLOCAL-AGENCYSTATE CORPORATION 0 PARTNERSHIP =COUNTYAGENCY 0 FEDERALAGENCY CITY N E ST ZIP CODE ' P�O WITH AREA 0 E, � ^ `1/L JJJJJJ !L aci=A III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OFOWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRE _ ✓ hot biWIw, E:j INDIVIDUAL 0 LOCAL-AGENCY L7 STATE-AGENCY CTIFY • _ /v E-1CORPORATION = PARTNERSHIP (] COUNTYAGENCY FEDERAL-AGENCYAM STATEn ZIP E / P ONE i V41TH AREA DE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14T4--o V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bm b iMicalt = I SELF-INSURED lE]2 GUARANTEE 0 3 INSURANCE LJ 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION Ll IS 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: 1.0 II.O III.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTSTITLE DATE MONTHIDAYiYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY LOCATION CODE OP TION L CEfgSU,$TRACTx=OPTIONAL SUPVISORQDISTRICT CODE -OPT/ONAL LE� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION2- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM3A R6