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< tgOURGCS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W dam, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) I DBA OR FACILITY NAME , NAME OF OPERATOR p C F N ;; , ADDRESS 61 1NEAREST CROSS STREET PARCEL#(OPTIONAL) t/ C++ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA q-5 ,331, ✓BOX KCORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS 8 owner of UST is a public agency,complete the Wowing:name of supervisor of division,sedan or office which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR a .1IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS C 00 5�030 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: N ME( r FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 0 -9 3- i1 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 4511 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESSN^ ✓ box to indicate INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY '4 . 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITYNA x"tnn STATE ZIP CODE PHONE#WITH AREA CODE S 47 0 - 7-7 - 36 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW ER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- -I 0 I 0 I z1 qTq V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION ®7 STATE FUND 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 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 INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ III.O THIS FORM HAS BEEN COMPLETED U DER 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 MONTHIDAYNEAR Z6;�a I -2,0�' LOCAL AGENCY USE ONLY If COUNTY# JURISDICTION# FACILITY# EE00 q0 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL J /j THIS FORM MUST BE ACCOMPANIED BY AT LJRT(1)OR MORE PERMIT APPLICATION- FORM B,UNLESJMS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORMW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROTORAGE TANK REGULATIONS FORMA(6-95)