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' f STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A w� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT F:] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION -�J�'y'/��7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE/ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) V ORA OR FACILITY AIE NAME OF OPERATOR ADDRESS }� NEAR ST CROSS ST PMCELakOPrpNAU o� t e CITYNAME/-,� STATE ZIP CODE SITE PHONE a WITH AREA CODE Jox A..�k CA TO DIICATE Ix CORPORATION Q INDIVIDUAL Q PARTNERSMP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY' Q FEDHWLAGENCY' 'N owner of UST is a public �agency,mrtplete the followin :name of S DISTRICTS' g upervisor of CNkbn,section,or office Which oparatee the UST TYPEOFBUSINESS O I GASSTATION Q 2 DISTRIBUTOR Q '/ IF RESERVAINDIAN aOF TANKS AT SITE E.P.A. I.D.•(bbijamo TION 0 3 FARM Q 4 PROCESSOR be 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAS ,FIRST) PHONE a ITM AREA CODE 43,411 , e r r �- 0�,o i3 ao - 6 NIGHTS: NAME(LAST,FIRST) PHONE WI H AREA CODE NIGHTS: E(LAST,FIRST) PHONEY ITH AREA CODE 11 t( II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE QF ADDRESS INFOPTION _ tv 'S vi MAILING OR STREET DRESS j /n^.�� ✓ Bocbi Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY 9 15I �TNL4YI V \/ CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL#GENCY CITY NAME / 21P CODE NE a ITH AREA oT III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION lz� J4 MAILING OR STREET ADDRESS IT ✓ bmbWkae Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box bYMkale Q t SELF-INSURED 0 2 GUARANTEEQ,7 INSURANCE A SURETY BOND Q 5 LETTEROFCREDIT Q 6 EXEMPTION 9e 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. ) Q CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.O III.a THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY Old tdec� ,IbJ- 3 7 COUNTY# JURI�# FACILETY# Lf b v LOG& E -OPTADAML CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT -OPTIONAL 00 7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE RF OILY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA FORMA 1393) FOR6a1N417