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• • o STATE OF CALIFORNIA .°`s STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �° n COMPLETE THIS FORM FOR EACH FACILITYISITE In MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOS GI ONE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S Z66 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF CILITY NAME NAME OF OPERATOR 5 ADDRESS� NEARESTOS/6 STREET PARCEL#(OPTIONAL) t N 0 CIN NAM STATE ZIP CODETE PHONE#WITH AREA CODE Tf CA ' — oz-- ✓ BOX O CORPORATION E::] INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY' I::]STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS H ownerd USTis a public agency,mplete the lolbwing:=e d supervisord dWicn,seclbn at office Mich MeMes the UST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF IRESERVATION NDIAN #OF TANKS AT SITE E.P.A. I.D.#(options)) n ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME( ST,FIRST) PHON #WITH AREA72CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE "4141 /� -3zp vv NIGHTS: NAME(LAS ,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAAM/E�� ^ CARE OF ADDRESS INFORMATION e CO -r641- A!/� D_ MAILING RSTRFET,�AIDDRESS ✓ ndelo'rCct'.a Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY 6O 3� O CORPORATION O PARTNERSHIP = UNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE C PHONE 05ITH AREA CODE ,iG✓Ji1 T6 � !)075' 6 Z�Jc�l —� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM�E�O/FLO� NER CARE OF ADDRESS INFORMATION 0 . -5 "a Y MAILING OR STREET ADDRESS ✓ butondirale O INDIVIDUAL nLOCAL.AGENCY O STATE-AGENCY D. O CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE# ITH AREA CODE �A TEol9YJr3� ' adv IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4 -1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 ( SELP-INSUREDGUARANTEE Q 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT O 6 EXEMPTION ]STATE FUND O 6 STATEF ND&CMIEF FINANCIAL OFFICER LETTER O 3 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT. O MECHANISM O 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 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 OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k FACILITY# ^_ 54 o Z I LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL L3� I zr qq THIS FORM MUST BE ACCOMPANIED BY AT LEULT(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE 0 SITE INFORMATION ONLY. FORMA(6-95) OWNI R MUST FILE THIS FORM WHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIVORAGE TANK REGULATIONS 1