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STATE OF CALIFORNIA W x.o a'� STATE WATER RESOURCES CONTROL BOARD x�� - m o ROUND STORAGE TANK PERMIT APPLICATION - FORM A , COMPLETE THIS FORM FOR EACH FACILITY/SITE le �A.(, p1 -., F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � TI T PERMANENTLY CLOSFE 1'Vt" I'W~ /`� O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE T!_ I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) OBA FACILITY NAME NAME OF OPERATO �1 =-�Ge ADDRESS NEARES CROSS STREET PARCELR(OPTIONAL) / o i✓z eT CITY NAME STATE P CODE SITE PHONE#WITH AREA CODE CA x'33 C ✓Box Q CORPORATION N DUAL Il PARTNERSHIP I1 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS Hamer of USTis a wb6c agency,complete the folbwng rams Of mpervisDrof dHision,section or office m6 operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORO ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS' NAME(LAST.FIRST) PHONE N WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE [A4/1a zo9-8?�S-�/l86 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE 0011?PLFTFO) NA CARE OF ADDRESS INFORMATION MAILING OR STVrET ADDRESS ✓ bcx la nCCYe 14'OMDUAL O LOCAL-AGENCY STATE-AGENCY /'06S ��(( QCORPORATION PARTNERSHIP 000UNN AGENCY FEDERAL-AGENCY CITY NAME % STATS_ 21P CODE p PHONE M WITH AREA C-DE //J�/nN/IL,eNL /T/!Lr 6 �y— III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM&QF OWNER �n CARE OF ADDRESS INFORMATION �TI MAILING OR STIRS E ADDRESS ✓ boxto Indicate *.IaDIVIDIIAL O LOCAL-AGENCY D STATE-AGENCY a�� O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CI N E STATE' ZIPCODE 6 PHONE .0q—gREACODE /S6 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(916)322-9669 if questions arise. TY(TK) HQ 1414- -❑ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate .42'fSELF-INSURED 11 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND ED 5 LETTER OF CREDIT Q 6 EXEMPTION = D STATE FUND Q ESTATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 6 CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 OTHER — V1. 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 it.�nl It. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT T KOWNER'S NAME PR TED SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/NEAR �tL5R1F� r- tw-�y LOCAL AGE CY USE ONLY COUNTY It JURISDICTION# FACILITY M ED 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. OWNER MUST FILE THIS FOISITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGO STORAGE TANK REGULATIONS FORMA(6-95)