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66�q C STATE OF CALIFORNIA ! " STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY f NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE . ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR _ L +(O ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) r YV%-o v CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA CA ✓ Box TO INDICATE CORPORATION =INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' = FEDERAL-AGENCY' 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 ® t GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P NE#WITH AREA CODE I aV - 0S 7 fr Capt) gf7-fS6y II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION 5 �'C1, i t F Ct>�j CA TMCA MAILING OR STREET ADDRESS ✓ box loindbals 0 INDIVIDU LOCAL-AGENCY Q STATE-AGENCY © 4 a©- ,A 4 54 CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER c CARE OF ADDRESS INFORMATION MAILING OR ST,kEETADDR S r� ✓ box b indicate INDIVIDUAL (] LOCAL-AGENC STATE-AGENCY Q 2 (�CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME , STATE ZIP CODE PHONE#WITH AREA CODE 14L IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ4 4- - '-��( -- p Q 7 Ll V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box b indicate W 1 SELF-INSURED 2 GUARANTEE FZ9 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT 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.[:] II.;K Ill.,X THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# rl m Q ��IS LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPnOMIL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI 0 vi� FORM A(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE tNIDERGROUN "ORAGE TANK REGULATIONS