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STATE OF CALIFORNIA �F 'o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE c'`'•°"" MARK ONLY F__j t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE REM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE GZ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) r)RA OR FACILITY NAME NAME OF OPER TOR / ,,.� op EV O `"`— ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) 2361.1 111� 037-/C'C' 457 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 1-0 DtT- CA �D BOXCORPORATION 0 INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' FEDERAL-AGENCY '(�INDICATE ' DISTRICTS' It owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESSI GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) RESERVATION Q 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#W H AREA CODE �r< Al c.�l 6�-�ash A � S DSS NIGHTS: jE(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME((LAST,FIRST) PHONE#WITH AREA CODE -I- 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME G MAILING OR STR_E�T A�RESS ✓ box b indkate INDIVIDUAL (] LOCAL•AGENCY �STATE-AGENCY 1%/11 ES //I F--1 CORPORATION PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME ��/ 1 G•I t STATE ZIP CODE ,,/ PHONE WITH ARI COD III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OVINER� CARE OF ADDRESS INFORMATION MAILING ORIIST EETADDRESS ✓ boxtoindicateDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY IN NAME STATE ZIP ODE PHONE#WITH AREA CODE IWAT �� Z17,33-6-3 0 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4_14- - O 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ 1 box bindicate SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE i�4 SURETY BOND 5 LETTER OF CREDIT 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 checked. CHECK ONE BOX JNDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. Ill.❑ 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 MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILrTY# Q LOCATION CODE -OPTION4L 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 I MATION ORLY. OWNER MUST FILE THIS FOAM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOP4033Aa7 FORM A(3193)