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�y-Unce.q STATE OF CALIFORNIA ^: '"" STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� a ` + COMPLETE THIS FORM FOR EACH FACILITY/SITE o i.o MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION ❑ 7 PERMANEAM.Y.CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ( 1 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME IT NAME OF OPERATOR ADDRESS 'rj '("�'r L � e NEAREST CROSS STREET PARCEL#(OPTIONAL) I e v q000 fit CIN NAME /� 1, STACEY ZIP CODE SITE PHONE#WITH AREACODE�� c f ✓ BOX TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LO( TO Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTORQ ✓ IF INDIAN j#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional i DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ` 1. Z U NIGHTS: AME(LAST,FIRST) PHONE#WITH AREA CODE "NIGHTS: NAME(LAST,FIRST) PHONE#WITH AR A I II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME ` CARE OF ADDRESS INFORMATION Gv tr nl MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE 7iFCODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION (MUST BE COMPLETED) t NAME OF OWNERCARE OF ADDRESS INFORMATION poo L- MAILING OR STREET ADDRESS• n ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 1 I n t$ V Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME' STATE ZIP CODE PHONE#WITH AREA CODE S711l� L� S" 1 io9'- lef IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14F - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box IDindicate Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 W141CH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR /V LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# . FACILITY# Ci �— 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 INFORMAT) I FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR3 Rs 1