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pfa.- ,8 C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 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 Q 7 PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR G}j kl ON `Z' -rte) S )t4G, ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 1 T 1 -, R (.- Hou-.OW CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ,T3ZA CA Z09-gsG®3 1 ✓BOX 21 CORPORATION 0 INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY° a STATE-AGENCY' Q FEDERAL-AGENCY° TO INDICATE DISTRICTS If owner of UST is a public agenr.Y,complete the following:narrre of superAsor of division,section or office which operates the UST TYPE OF BUSINESS Ey 1 GAS STATION Q 2 DISTRIBUTOR0 RESERVATION IF INDIAN!#OF TANKS AT SITE E.rP.pA. 1.D.#(optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS L ry D 1 J 71 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY�NgM�E(LAST,FIRST)E IA'� PHONE#WITH AREA COD® � DAYS: NAME(LAST, T)) �``'V PHONE#WITH AREA CODE gIX NIGHTS: NAME(LAST,FIRST) /G,PHONE#WITH AREA CODE NIGHTS: NAME(LAST,ST,FIRST) PHONE#WITH AREA CODE ai G(fLe-11, pct. nl II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILINGOR STREET ADDRESS V, box to' e 0 INDIVIDUAL F-1LOCAL-AGENCY0 STATE-AGENCY CORPORATION ®PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE E2&1: Z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY ox - CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE� ZIP CODE PHONE#WITH AREA CODE_ n IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. S- TY(TK) HQ 4 4 - 3 I / ! V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to irate 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT O 6 EXEMPTION =7 STATE FUND 9 STATE FUND$CHIEF FINANCIAL OFFICER LETTER (=1 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 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.❑ ll.0 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK O ER'S NAME INTED&SIGNATURE) TANK OWNER'S TI DATE MONTHIDAYNEAR ®d I a3/2 9195 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If FACILITY If EE FTT-1 - - 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 FOPANIVH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRnLam STORAGE TANK REGULATIONS FORM A(6.95)