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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 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL B— ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA RFACILITY NAME / �/5 �`YQ C \0 NAME OF OPERATORo Q ct AJ ADDRES/jam\ S /V— /`J` NEARE$,FTIICRO/�S/S/STREET PARCEL If(OPTIONAL) CITY NA� C 20 T C.ASTACE4 � ZIP CODE PHONE#WITH AREA CODE ✓BOX CORPORATION INDIVIDUAL IPARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY` (] STATE-AGENCY` FEDERAL-AGENCY` TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS [�l GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.If(optional) RESERVATION 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ao r f��.� C x'10 �.A til zocr -NIGHTS: NAME NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION E go do CA) &U1 RaA-I CHH �¢P AILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY D i WQ CORPORATION ; A TNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE TCA) C - Za 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION k1l. Id., &A21j, Lvel CI 2s� at)� )L) MAILING OR STREET ADDRESS I o ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY V f �a�-+ fh,; W�( CORPORATION []'PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME 1 STATE ZIP CODE PHONE#WITH AREA CODE o;U e'il IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED [:j 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION =7 STATE FUND O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 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 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.5?1*- It.❑ 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# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I 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 FORM WIT4 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROV''ND STORAGE TANK REGULATIONS FORM A(6-95)