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" STATEOFCAUFORNlA STATE WATER RESOURCES CONTROL BOARD ., � a UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY D t NEIN PERMIT 0 3 RENEWAL PERMIT Is5 CHANGE OF INFORMATION E::] 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESSNEAR TCROSS TRTE PARCEL#(OPTIONAL) �p til/ 4f� �. rel CITY NAME STATE ZIP CODE ,SITE PHONE s WITH AREA CODE, CAV Box TO INDICATE CI CORPORATION INDIVIDUAL © PARTNERSHIP © LOM-AGENCY []COUNTY-AGENCY' (]STATE-AGENCY' © FEDERAL-AGENCY' DISTRICTS' d owner aI UST Is a public agency,complete the toaowing:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS�-1 GAS STATION Q 2 DISTRIBUTOR = RESERVAT s OF TANKS AT SITE E.P.A. I.D.s(aptkmU) 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE o S ZaS Zell NIGHTS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME{LAST,FIRST) PHONE s WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate M INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY O S4 =CORPORATION Ej PARTNERSHIP ©COUNTY-AGENCY FEDERAL-AGENCY C$TY NAMESTA ZIP CODE PHONE s WITH AREA CODE Glop' 9 z III. TAMC OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL 0 LOCAL-AGENCY Q STATE•AGENCY CORPORATION = PARTNERSHIP © COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE P ONE M WITH AREA CODE �G talc Z i� 9 3-2_,,�,( IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY CM) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ fm bindirale I� t SELF-INSURED a 2 GUARANTEE Q 3 INSURANCE Q 1'SURETY BOND 5 LETTER OF CREDIT 8 EMMPTION (] 49 OTHER I I 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: T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNfTY# JURISDICTION a FACILITY 8 _ i LOCATION CODE -OPTIONAL CENSUS T�RA-+C�T# -OIPTKWAL SUPVISOR-OISTRICT CODE - mL V 0 'r-9112 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE MVRMATION ONLY. OWNER MUST FILE THIS FORST WITH THE LOCAL AGENCY IMPLEAIENTING THE UNDERGROUND STORAGE TANK RIEGULATKM FORM A{3183} - /Jr FORpp53A.it/