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'v • { f g r CgOUMCIS STATE OF CALIFORNIA t STATE WATER RESOURCES CONTROL BOARD P UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE t� ' •CSI IRON Nr� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR u ; G�. ? E ADDRESS NEAREST CROSS STREET PARCEL It(OPTIONAL) TY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE k�'e� CA ` .a.:?G 41 ✓BOX E:1 CORPORATION INDIVIDUAL PARTNERSHIP (]LOCAL-AGENCY Q COUNTY-AGENCYSTATE-AGENCY` Q FEDERAL-AGENCY' TO INDICATE DISTRICTS '8 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 1 GAS STATION ❑ 2 DISTRIBUTOR a ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.It(optional) F RESERVATION 3 FARM ❑ 4 PROCESSOR = 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(LASf,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFT-D) NAME E S INF 4MATION do ------------ MAILING OR STREET ADL)RESS C ✓ bcx to iiW.` 0 INDI�UAL 0 LOCAL-AGENCY STATE-AGENCY j x -.% F+yd� roy cp ✓ i I�CORPORATION ] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 3 fft- pfN -101 ER--INFORMATION---(MUST BE COMPLETED) ✓ f / ///� , N EF) ?` tc_- C FA ORES NFORMATI�N AILING EET A D SS T[ % ✓ box to indicate T✓g��^INNDIIV+IIDUAL LOCAL-AGENCY F7 STATE-AGENCY C JT/ � V =CORPORATION 'PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME / STATE ZIP CODE' PHONE#WITH AREA CODE Fl l L y IV.BOARD OF EQUA RATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4]74- - d V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED),-IDENTIFY THE METHOD(S) USED- ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE =4 SURETY BOND 5 LETTER OF CREDIT O 6 EXEMPTION 0 7 STATE FUND 0 B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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❑' II.❑ III.❑ • I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) . TANK 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 FOR;W THE LOCAL AGENCY IMPLEMENTING THE UNDERGR 'STORAGE TANK REGULATIONS FORMA(6-95) i