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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE t� MARK ONLY ,..1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 07 PERMANENTLY CLOSE TE ONE ITEM ^2 INTERIM PERMIT F-1 4 AMENDED PERMIT E—] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) SS DBA O FACI TY E NAME F OPE R Y�`r / �L�GGJ � �rr� Q►� ��, ADDRESS // NEAREST CRO ET PARCEL#(OPTIONAL) { CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE -:10piqlao. I CA ✓ BOXCORPORATION Q INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY 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 I#OF TANKS AT SITE E.P.A. 1.D.#(optional) RESERVATION 1 02 E � 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS k EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional 9 DAY& N M€(LAST,FIRS „ PHONE#WITH AREA CODE / DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE — I NIGHTS: NAME(LASIT,FIRST PHONE-#WITH AR CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ..r .rr r IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) t j NAs� � CAREQFADDRESSI MA ION MAA� /� l If'f MAILING OR STREET.ACIDRESS " ✓ fox to indicate DIVIDUAL LOCAL-AGENCY STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME, � �J y � ZIP CODE PHONE#WITH.AREA CODE III. TANK OWNER INFORMATION--(MUST BE COMPLETED) NAME OF OWNE V CARE OF ADDRESS INFORMATION k MAILING OR STREET ADDRESS ✓ boxto indicate INDIVIDUAL Q LOCAL-AGENCY OSTATE-AGENCY 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY G FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE I I i IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - J V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE =4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION O 7 STATE FUND 1 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 99 OTHER j 1 r VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. i CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. it a i C 1 THIS FORM HAS BEEN COMPLETED UNDER PamALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK,��"ER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE " DATE MONTH11*YNEAR LOCAL AGENCY USE ONLY I COUNTY# JURISDICTION# FACILITY W LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL I�. � 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 FOR FORMA(6-95) THE LOCAL AGENCY IMPLEMENTING THE UNDERGRTORAGE TANK REGULATIONS I ;