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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL0."p SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR 7 ok`civs+A14E /c.5vf/ �/►-y qqQQR¢� NEAREST CROSS STREET PARCEL 4(OPTIONAL) CITY NAME STATE ZIP CO TE PHONE#WITH AREA CODE GGF.�t�� T�7 CA 922 �S.c� Z87—/627 ✓BOX O CORPORATION Q INDIVIDUAL F-1 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS Nomerol UST'sepubkagency,=PIMethafalMWn9:name of supemord division,seclbn ora#cex Iclh operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTORRE EIRVATIONF NDIAN #OF TANK'AT SITE I E.P.A I.D.#(optbnal) ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EME GENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIR T) P ONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE G# rx1�.4 si��"zS� NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION )c .!S. .- v. �. MAIL GOR STFIET ADDRESS ✓ box to ndcala Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY Q- �,I �//�ZLJIQ� 0 CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY TH AREA CODE CITY A VIJY—� �(+7 IP)Wl#+D 7�� III�TANK OWNER INFORMATION-(MUST BE COMPLETED) VIP) NAMEOF OW ER CARE OF ADDRESS INFORMATION F. / - h • v, tl MAILING OR STREET ADDRESS ✓ bmtoindme Q INDIVIWAL O LOCAL-AGENCY 'vO STATE-AGENCY v -4 0-5-G, [::]CORPORATION O PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STAT ZIP CODE HONE#WITH AREA CODE 0Arl oAyj vel ?y6Z3 /oSs plio) zs7 Adv IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4- - O 2i 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box loi dicate 1 SELF-INSURED = 2 GUARANTEE C]3INSURANCE =4 SURETY BOND Q 6 LETTER OF CREDIT =6 EXEMPTION =T STATE FUND D8STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM 099 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.❑ it.X It.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ED 1/ 1 1 f� LOCAZON CODE-OPTIONAL CLAUS TRACT -OPTIONAL SU �OVR-DISTRICT CODE •OPTIONAL S 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 FOR jr THE LOCAL AGENCY IMPLEMENTING THE UNDERGRI,&STORAGE TANK REGULATIONS FORMA(6-95)