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• ssoon ey c STATE OF CALIFORNIA ^e STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A Ue C�a,nOn M� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 1 C% 7'f 0_� � �70 ADDRESS NEAREST CROSSS� REET PARCEL#(OPTIONAL) VA'1.� vlt✓ A1� �✓ 7/'r' / CITU NAME STATE TZIP CODE SITE PHONE#WITH AREA CODE ,5�1ptle- CA S2oZ ✓ Box TOINDICATE E::)CORPORATION INDIVIDUAL 0 PARTNERSHIP Pffl`16CAL-AGENCY E-1 COUNTY AGENCY l] STATE-AGENCY 0 FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR = gESEIRVADIAN #OF TANKS AT SITE E.P.A. I.D.#rophwal/ ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE_V_WiTIA�CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME C` a`(` � ^ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS Y /� f^ ✓ box bindbate 0INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY Z N• £,\ nEw- l`C' O CORPORATION IEj PARTNERSHIP E::] COUNTY-AGENCY 0 FEDERAL-AGENCY CITYNAME STATE ZIP CODE PHONE#WITH AREA CODE S ki:5,�Ww" If C, zo z z&,F 9vy kzz III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ^�rv1C Q s MAILING OR STREET ADDRESS• ✓ box blWicate Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY CORPORATION Q PARTNERSHIP (]COUNIYAGENCY FEDERAL-AGENCY CITY NAME- STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)323-9555 if questions arise. TY(TK) HQ F4_141 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED ✓ boa bindkale L--"I SELF INSURED E::]2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND L�l 5 LETTER OF CREDIT 0 6 EXEMPTION N 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.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY CO3UN�# I>-77 j�T] JURISDICTION# �[/5�I< F LOCATION CODE OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL i/9i ^ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMALT.IIOJN ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUL ONS FOROW3A R6