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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 In MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSEDpSITTE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE wJ 13 fl I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D/'f ABA OR FA ILITY NAME NAME OF OPERATOR v. S.r7• Geov.�5 S/�I� ADDR S NEAREST CRp SS TREET PARCEL N(OPPONAL) �6v mac+ I LSSSaIL- S': 1L.45N.,�L-re,� /CISTCog E V4rR EASGS^ae� zool trt� ✓BOX 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' ❑FEDERAL-AGENCY' TO INDICATE DISTRICTS H ownero(UST N a public agency,=plate the following:name of supervisor N division,swdlon ora#ice which opeones the UST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF ATION RESERVINDIAN MOF T/ CS AT SITE E.P.A. I.D.M(optional) ❑ 3 FARM ❑ 4 PgOCESSOR ❑ 5 OTHER OR TTRUST LANDS `— EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME41L 11pHT IT}IAV ODE_ DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE IL PROPERTY OWNER INFORRIATION-(MUST BE COp4PLFTFD) NAMECAREOFADDRESS INFORMATION MArG OR STREE�TAD^^DRESS ✓ =Ic cCo'a QIKDNIDUAL LOCAL.AGENCY = STATE-AGENCY CORPORATION Q PARTNERSHIP OUMY-AGENCY = FEDERAL-AGENCY CITY NAM ST E ZIP,#D4 33� N:' WITH�gC DE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OFO NERCARE OF ADDRESS INFORMATION ,1&ro 1 d9 v, s. 7. MAILI GOR STRE ADDRESS .1 box to ndigte 0INDMDUAL LOCAUAGENCY STATE-AGENCY Q- roc �� (]CORPORATION l=PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY CITY NPM STATE ZIP CODE PONE I AREA ODE /•'s'� 7SO4 95336 (Zo KZ1,-32coc_> 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 to schools I SELF-INSURED [_-)2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND [1:15 LETTEROFCREDIT Ll 6 EXEMPTION 0 T STATE FUND D B STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT = IO LOCAL GOVT.MECHANISM = 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it. yr III.❑ 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 OWNERSTTTLE DATE MONTWDAYYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY If i T ® FTT 115101'WI7-11 17 Irl"/o LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST RE ACCOMPANIED BY AT(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(695) OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR®STORAGE TANK REGULATIONS