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STATE OF CALIFORNIA ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILQYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION © 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT 1--] 6 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE I 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ORF IUTY NAME NAMEOFOPERATOR 10 Pa .S .[) , �OI^ouNds 7 ADDRESS p f /y��/a/w�c(gq�Cp, ro ONAU UJ(av M( Si (� "Voss 10u55 EEr PARCEL, PII CITY NAME STATE ZI CODE SITE PHONE#WITH AREA CODE ftGvt��CU CA �s3�� Zd"ll s-.c 37uz) v BOX EJ TO INDICATE TO INDIVIDUAL _Q PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGBICY• O STATE-AGDJCY• �FEDERAL-AGENCY• DISTRICTS •Eoxnerd USTuapuhbc egerry,oXrybte the Wowing ramedsuyervisord derision,seupnor ogre whkh opown the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓IF INDIAN N OF TANKS AT SITERESEpp.^P.,,A. (options)/) ❑ 3 FARM - Q 0 PROCESSOR A 5 OTHER OR TRUSTVATION LANDS � O-) �BQ •7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional i`1: NAME(LAST, ZEST) �7 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE A� `UL�.3Z�D NIGHTS. NAME(LAST,FIN ST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION - AIMAILING�OR STREET ADDRESS ✓ boxio Yxbale QINDMDUAL LOCAL-AGENCY STATE-AGENCY O CORPORATION O PARTNERSHIP O COUNTY.AGENCY FEDERAL-AGENCY G �n E �P C CA STT ZIP ODE PHONE#WITH AREA CODE < 2UV III. TANK OWNER INFORMATION -(MUST BE COMPLETED) NAIE OF OWN R CARE OF ADDRESS INFORMATION "tA ,f'C G IA. I--) . MAILING ORETADDRESS r� ✓ bextoldole Q INDMDUAL LOCAL.AGENCY D STATE-AGENCY X `� 0 CORPORATION [:] PARTNERSHIP ED COUNTY-AGENCY Q FEDERAL-AGENCY CI�,y NPMELP ODE ONE#WITHAREACODE �VIGIM { C f o. !l `i L 3? PHZ� 42C-32az> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4 -� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate O I SELF-WSURED 2 GUARANTEE =3INSURANCE =A SURETY BOND Q 5 LETTEROFCREDIr =6 EXEMPTION (]7 STATE FUND ESTATE Fl1NDdC IEF FINANCIAL OFFICER LETTER l=9 STATE RIND d CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 990THER 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 ABOVEADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III.O THIS FORM HAS BEENCO P ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT 'S NAME(PRINTED R - s TANKOWNER'S TLE DATE MONTH/DA ael< M 1� /�c �� dw�e � LOCAL AGENCY USE ONW' COUNTY# JURISDICTION Y FACILITY#7q9 m Lsaga 1111 1-1t-4's IOCATON CODE •OPTIONAL CENSUS TRACTtl -OFT/ONAL SUPVISOR-DISTRICT CODE -OP710NAL IIu THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SIT FORMATI N ONLY. FORM A(6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROt ORAGE TANK REGULATIONS