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0 '�sowccs c STATE OF CALIFORNIA 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE n I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE --�� MARK ONLY / ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ;❑ 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 3 I NAME OF OPERATOR DBA OR FACILITY NAME ��R CAI—/ /�� NEAREST CROSS STREET PARCEL # (OPTIONAL) �+ ADDRESS STATE ZIP CODE WE PHONIk # WITH AREA CODE CITY NAME CA I - J / ✓ BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP a LOCAL -AGENCY V COUNTY -AGENCY' IJ STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS ' H owner of UST is a public agency, comptete the following: n me of supervisor of division, section or office which operates the UST - v, IF INDIAN J TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR u RESERVATION # OF TANKS AT SITE E P. A 1. D. # (optional) ❑ 3 FARM ❑ 4 PROCESSOR 05 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 CODfipLFr;;D1 (: iff Gni MAILING OR STREET ADDRESS >? a- .9 a"X- CITY NAME CARE OF ADDRESS INFORMATION ✓ ;cxUr_ - —1 NC',VIDUAL CORPORATION PARTNERSHIP S I AT ` ZIP CODE zd 4--) t 7z)X LOCAL -AGENCY STATE -AGENCY Q COUNTY -AGENCY Q FEDERAL -AGENCY I PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 0.1'e-1 /'— / '1/ MAILING OR STREET ADDRESS I ✓ box to ndrace � INDIVIDUAL Q LOCAL AGENCY I_f STATE AGENCY 7 J CORPORATION PARTNERSHIP = COUNTY -AGENCY (� FEDERAL -AGENCY CITY NAME / I STATE I ZIPC DE PHONE #WITH AREA CODE ij J % IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ F4747- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE = 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND = 8 STATE FUND S CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND d CERTIFICATE OF DEPOSIT 10 LOCAL GOVT. MECHANISM O 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. ❑ 11. ❑ III' 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ANK OWNER'S NAME (PRINTED & LOCAL AGENCY USE ONLY TANK OWNER'S TITLE COUNTY # JURISDICTION FACILITY # m�Z,/z/�-P 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 F0 -H THE LOCAL AGENCY IMPLEMENTING THE UNDERGO i T ORAGE TANK REGULATIONS FORM A (6-95)