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ESOUR FT STATE OFCALIFORNIA t� STATE WATER RESOURCES CONTROL BOARD a01 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <��" �: COMPLETE THIS FORM OR EAC ACILITY1SITE 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS MARK ONLY � � ❑ ONE ITEM [__i 2 INTERIM PERMIT F-1 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIII,ITY NAME NAME OF OPERATOR ADDRESS� � v � � �� NEAR ST CROSS ST EET PARCELp(OPTIONAL) CITY NAME STATEZIP CODE SITE PHO N�E WITH AREA CODE CA�qFj Z.cf v v/Y�UDw TO INDICATE I]CORPORATION 0 INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY L-3 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS1 AS STATION 2 DISTRIBUTOR RESER F INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LA)T,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) - -_ RHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDREfSS ✓ box No indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY 1Z 3w3___,4/- /i; V Al CORPORATION [] PARTNERSHIP [] COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAMESTATE ZIP C09j; PHON #WITH AREA CODE �o0� GQ �yz Z� -4--A/ow III. TANK OWNER INFORMATION--(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE WITH AREA CODE vwi IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14 j 4 I- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1SELF-INSURED Cj 2 GUARANTEE [] 3 INSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT =6 EXEMPTION E-] 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: L n it.y III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PR'NTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNT Y u JURISDICTION# Y-4 3� 1_-L 11 15-157 LOCATION CODE OPTIONAL CENSUS TRACT tt -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL , . THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION rNLY. ORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-