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�n e STATE OF CALIFORNIA .e`�.�,•• eO STATE WATER RESOURCES CONTROL BOARD a` � 9 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� : � . oa OWN.\ COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED LITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6Z I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME NAMEOF OPERATOR 6i,.-a AjaADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) Z -7y Gf,4 CITYNAME STATE ZIPCOOQY5 z 51 PHONE a�116I 7REA30, v TO INDICATE,`QvO CORPORATION Q INDIVIDUAL = PARTNERSHIP 0 LOCAL AGENCY �,COUNTY--AA'GENCY STATE-AGENCY /'��/FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) �77A�_�ELL ? 75�i-3o/DPHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box WIndbale L:j INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY Bp CORPORATION E::] PARTNERSHIP 0 COUNTY-AGENCY E:1 FEDERAL-AGENCY CITY NAMESTATE ZIP COD PHONE#WITH AREA CODE 065"f147; C4 43ZZ7 /SR_30/n III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER "� CARE OF ADDRESS INFORMATION 6G- Ai /P-4rluy MAILING OR STREET ADDflESS• ✓ box biW.M. 0 INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY / 14� CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME' --II STATE ZIP CODE PHONE#WITH AREA CODE GL6�iF,.17 9S2Z oq� 7 - 30/0 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L414]-�T" V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box m indicate O I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT O 6 EXEMPTION 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: I.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION It FACILITY# �11 04 - - LOCATIONCODEOPTIONAL iCENSUS TRACT#OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL 23. 57 -191-1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0G37ARfi