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'fSpunces o STATE OF CALIFORNIA Ar ° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE t>3 •CSI IIpR N,r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT n CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT u,(6 TEMPORARY SITE CLOSURE !!1111 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 130 9. 0—pvtiN CITY NAME STATE ZIP CODE SITE PHONE#WIT AREA CODE ✓BOX IrCORPORATION O INDIVIDUAL D PARTNERSHIP Q LOCAL-AGENCY D COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATEDISTRICTS N owner of UST is a public age ,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS fV 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) IF Q 3 FARM Q 4 PROCESSOR Q 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 CARAr--c=k(AI�JA % w ern 'JI -- " -3 -x '*? 6;APr-z=1c.r'�j Pr (1K ,so . Q01")--3�-,a�%3 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 6RW—t',w,�A-, W m .. JR- 2-(-n ---MG-®'a Ci,t-°-V�Cni W Cn - 2'-, ?�—'_�-3363 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION GRA-I✓(=1 G�nI A 'I. ��RI��C��A— MAILING OR SSTRRE'ET�ADDRESS � ✓ box to indicate 0 IVIDUAL LOCAL-AGENCY Q STATE-AGENCY S� 1A1 � V�RIN — 0 CORPORATION FV PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE apt CA 5L - 332- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS r v1 box to indicate n 1�1IIDUAL I�LOCAL-AGENCY =STATE-AGENCY 145 1 �,� �`y�lr� �� 0 CORPORATION l,T✓�f_PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STA ZIP CQD � PHONE If WITH AREA CODE L�tJc Ul 2m --3--3-1-` IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ4 4- -1 12 [� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 7 STATE FUND D 6 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT D 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: I. II. 111.❑ THIS FORM HAS BEEN CO UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT LETED TANK OWNER'S NAME(PRINT &SI AT E) TANK OWNER'S TITLE # v DATE MONTH>DAYNEAR M► O�r�`— MC„R-, 1 ®40 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# Z FACILITY# LOCATION CODE -OPTIONAL CENSUS RACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT Lj&T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS /