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✓ RECEIvED STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD uft1k1 %UW%TORAGE TANK PERMIT APPLICATION - FORM A ENVIRONMENTAL HEALTH ` ` C, ;�> . • LETE THIS FORM FOR EACH FACILrrYiSITE MARK ONLY I NEW PERMIT � 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ~ 4 AMENDED PERMIT L� 6 TEMPORARY SIiiE CLOSURE 15 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME /�qy / t NAME OF OPERATOR 'D �p AD R S NEAREST CROSS STREET PARCEL#(OPTIONAL) C�IY NAME f� S CEA IP CODEO � SITE PHONE#WITH AREA CODE I/ BOX F_'CORPORATION INDIVIDUAL r! PARTNERSE:P n LOCAL-AGENCY �`��JJii TO INDICATE Q — t_, COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS C ) GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optimal) Q 3 FARM Q 4 PROCESSOR 5 OTHER RESERVATION TOR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE# TH APE CC E DAYS: NAME(LAST,FIRST) _ ao N HT AM (LAST,FIRST) PHONE# ITH AREA CODE NIGHTS: AME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMA ON- MUST BE COMPLETED! NAME CARE OF ADD SS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate NC7 INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION -ARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE `ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMP TED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box toindicate I^ INDIVIDUAL Q l AL-AGENCY STATE-AGENCY j J CORPORATICN Q PARTNERSHIP Q CCU -AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE ITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F744-1- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF-INSURED Q 2 GUARANTEEQRANCE Q 4 SURETY BOND 5 LETTER OF CREDIT -7 6 EXEMPTION 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.f--7, 11.0 III.7 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/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CO E OPTIONAL CENSUS Tx -OPT NA. SUPVISOR-DISTRICT CODE -OPTIONAL , L THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A 112 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-R6 Ab fro-/ �--' 11?3�"