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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION d7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS +� NEAREST CROSS STREET PARCEL#(OPTIONAL) S'7T CliAGrt/GT6i�ov� CITYNAMESTACA ZIP D� SITE PHONE#WITH AREA CODE T✓ BOX fa TOINDICATE O CORPORATION 0 INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 11101-3 OF TANKS AT SITE E.P.A. I.D.x(°ptam.1) 3 FARM 4 PROCESSOR ,�/5 OTHER ❑ RESERVATION ❑ ❑ Lw OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIflSn II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION a/-p /1 - MAILING OR STREET ADDRESS ✓ bor bintllcaU I� INDIVIDUAL 0 LOCALAGENCY0 STATEAGENCY Ac CORPORATION Q PARTNERSHIP Q COUNTY AGENCY E__I FEDERAL AGENCY CITY NAMES STATE I ZIP CODE PHONE It WITH AREA CODE T e� Lz> Z-1- 07s III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERCAPE OF ADDRESS INFORMATION �siQj 7� .'67./'7 . MAIL.N0R STREET ADDRESS• box bindicate l� INDIVIDUAL 11 LOCAL-AGENCYSTATE-AGENCY/_ X- / 5Q� OCORPORATION Q PARTNERSHIP =1 COUNTY-AGENCY E�j FEDERALdGENC YCITY STATE ZIP COD `9� HON WITH AREA DE � u/Ir 56 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 A SURETY BOND 5 LETrER OF CREDIT =6 EXEMPTION L-1 IN OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal not fication 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. 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 MONTWDAY/VEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# LOCATION CODE -OPTIONAL ICENSU57RACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 5'/' THIS ORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. FORM A(12 e1) FILE THIS FORM WITH THE AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A RG I