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�boun t STATE OF CALIFORNIA �� r s STATE WATER RESOURCES CONTROL BOARD c UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ® 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME ` NAME OF OPERATO C.Lsot, r ✓� ADDRESS NEAREST CROSS STREET PARCEL M(OPTMAL) Dr G AME STATE ZIP COE� SI�PHONE s WI MR n CA 2 TH AREA CODE Z3 I/ Box TO INDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' r DISTRICTS' H 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 Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) 1� RESERVATION 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 s WITH AREA CODE HZ'S t�t1GHTS: NAME(LAST,FI ` r PHONE o�TH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE 3 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS VD box b iMicais �INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY (1 Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CIT�ypi�E/ STATE. i ZIP OQE�I� PHONE x WITH AR CODE l//'/C-�1 i S III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N OF OWNE /� CARE OF ADDRESS INFORMATION (vim � MA ING O S RfET ADDRESS Yo ✓ box b ind"s INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Lwj • ! v Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY I STE� ZI,C p� PH NE aHZiFp E9 ZZ C S-75— IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-T47- -it) I 2jdq 12,111 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box ID indicate o t SELF-INSURED 2 GUARANTEE = 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION JX 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: 1.0 it.= III.= THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT r NER'S NAME(PRINTED 8 SIGNED) „�! OWNER'S TITLE DATE MONTHIDAYNEAR yi LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY 0e`C&,?S [3� P, 1 y �. K LOCATION CODE -OPTIONAL I CENSUS TRACT s -OPTIONAL TUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE 00 SITE WFORYATION ONLY. OWNER MUST FILE THIS FORM WITSLOCAL AGENCY IMPLEMENTING THE UNDERGROUND Sj&GE TANK REGULATKW 1-��' �D FORM A(3W)