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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ^ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) R FACILITY NAME NAM FOPS ATOR vGsan�` ILII NEAREST CROSS STREET PARCEL#(OPT NAL) CI Al STATE ZIP �/JD� SITE PHONE#WITH AREA CODE ✓ BOX CA L✓�� TO INDICATE CORPORATION [:j INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY D STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANI$S.AT P SITE E. .A. I.D.#(oPlianaq 3 FARM 4 PROCESSOR ❑ RESERVATION 11 OTHER `/T-7/9 ❑ ❑ 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓borbiMkate O INDIVIDUAL Q LOCAL-AGENCY E-1 STATE-AGENCY Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCYCITY NAME STATEZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• ✓ box b Wicab QINDVIOUAL Q LOCALAGENCY = STATE- AGENCY =CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY D FEDERALAGENCY CITU NAME' - STATE ZIP CODE PHONE 0 WITHAREACODE 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 COMP/TED)—IDENTIFY THE METHOD(S) USED ✓ boa binbiaale O I SELF-INSURED 4UARARTEE (] 3INSURANCE O5 LETrEROFCREDT O 4 SURETY BOND 6 E%EMPTION �] 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 OF MY KNOWLEDGE,IS TRUEAND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT•STITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILI`--1-6- -'-"��I 39! cr-wse4ZZ_L LOCATION CO IjU�/OPTIONAL CENSUS TgACT# -qQ7/(SAL- SUPVISO •C3( - IS I TCODE -OPTIONAL 23J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITEI F MATION ONLY. FORMA(12-e1) FILE THIS FORM WITH T�CAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGU LAT FORD'