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t60u' e, \iC STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W �� jiba UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLCTETHIS FORM FOR EACH FACILITY/SITE MARK ONLY L_1 t NEW PERMIT E:j3 RENEWAL PERMIT [2-15' CHANGE OF INFORMATION 07 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE j I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME RATOR GG r � J e IIOF,^�OP1 A� W' I c at wt / �' r t ADDRESS X13 �-e NEAREST CROSS STREET PARCEL If (OPTIONAL) I S LJ' 4 r � oc7 ZIP CODE S Z PHONE s WITH AREA CODE 0 1,7G /y/ '50 CITY NAME 1 STATE ZIP CODE SITE PHONE s WITH AREA CODE CA j ZOS ✓ BOX ORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' [� STATE -AGENCY' 0 FEDERAL -AGENCY' TO INDICATE DISTRICTS' If owner of UST Is a public age n mplete the following: name of Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS t GAS STATION 0 2 DISTRIBUTOR 0 ✓ IF INDIAN I# OF TANKS AT SITE E. P. A. I. D. N (optional) 0 3 FARM O 4 PROCESSOR = 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ootional DAYS: NAME (LAST, FIRST) PHONE A WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE o WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE x WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME I I e CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRE S✓ box ID indicate 0 INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY ,0 oO O 2 ORPORATION 0 PARTNERSHIP COUNTY -AGENCY (] FEDERAL -AGENCY CITY NAME STATE �'� ZIP CODE S Z PHONE s WITH AREA CODE 0 1,7G /y/ '50 rc0 III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER pmt- aS ( I CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box toindicate INDIVIDUAL LOCAL -AGENCY DSTATE-AGENCY CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE 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 bindicate I -i f SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND Li 5 LETTEROFCREDIT 0 6 EXEMPTION 0 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 CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. [:] II.`� [—]III. I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED & SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # - 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 ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWNS FORM A (3/93) FOR0033A-R7