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• • 6b° cc. STATE OF CALIFORNIA :� ...... STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A s - COMPLETE THIS FORM FOR EACH FACILITY/SITE 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. FACILITY/SITE INFORMATION&ADDRESS.(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 1 ADDREW �S(\ NEAREST CROSS STREET PARCEL#(OPTIONAL) IL . �_7�r L CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE AZo �-'s CA IS ✓ BOX ORPORATION O INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' a STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE 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 1 GAS STATION 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM Q 4 PROCESSOR O 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) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE O ADDRESS INFORMATION N C R I C LL ES i1\7 E MAILING OR STREET AD RESS ✓'box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY S 5 — k 4C)o CECCORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE L, � Az. �35� �2 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION V U R�� —)0 L U [C— MAILING OR STREET ADDRESS ✓ boxioindicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY U r 2 ORPORATION (] PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE HONE If WITH AREA CODE E P" - Zt) �- 6 555 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - 3 V. PETROLEU UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED Fbox to indicate 1 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND 8 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: I.❑ II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT rTANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR C,- I N �rvZ i o� of E� 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)