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STATE OF CALIFORNIA - STATE WATER RESOURCES CONTROL BOARD ay UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE t ie MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEJ�SEDSITE CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT FB TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED)DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS i/,_ N EST CR S STREET PARCEL k(OPTIONAG(f CITY NAME STATE ZIP CODE ITE PHONE#WI Zf wA CA 1C276G ZOs) Srlq - 7/03 ✓BOX Q CORPORATION E INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' D STATE-AGENCY' TO INDICATE DISTRICTS D FEDERAL-AGENCY' '#ownerol USTbaWb9c egenry,mmpblathe following of Supervisor of dwi on,smion or ol9ro which operates the UST TYPE OF BUSINESS ® i GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E P.A. I.D.k(optbnaq ❑ 3 FARM RESERVATION ❑ 5 OTHER OR TRUST LANDS UO( LW. -1`1z Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CE OD 5li - �(D NIGHTS: NAME k(LAST:FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE It. PROPERTY OWNER INFORMA ION-(MUST BE COMPLETED) NAME - CARE OF ADDRESS INFORMATION MAIL NG ORSTREET ADDRESS ✓ boxm ildrateINDIVIDUAL Q LOCAL-AGENCY ED STATE-AGENCY O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY E:j FEDERAL-AGENCY CITY NAME STAT ZIP CODE HONE k TTH AREA COD III. TALK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box londicale C] INDIVIDUAL 0LOCAL-AGENCY INSTATE-AGENCY IED CORPORATION �PARTNERSHIP ID COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATEZIP r HONE p ITH AR CODE IV- BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-F4--]-� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to ir4oale 0 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE L:1 4 SURETYBOND 5 LETTEROFCREDR = 5 EXEMPTION =7 STATE FUND O8STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND A CERTIFICATE OF DEPOSIT O10LOCAL GOVT.MECHANISM O 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.�' III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT TANK OWN E(PRINTED&9IGNATUR TANK OWNER'S TT DATE / MONTHYDAVNEA LOCAL AGENCY USE ONLY COU®NTY k JURISDICTION# FACILITY# v a LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(G95) OWNER MUST FILE THIS FORM q THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS .5 a5- q `�uf�M � °)JIB /-r,---i r- _t `I