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; r • STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ve COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O t NEW PERMITF� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT LJ 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORFACILITY NAME NAME OF OPERATOR C I S 6n Cad .4 S u n,—.¢_ ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAW CITYNAME STATE ZIP CODE SITE PHO E#WITHAREACODE CA 711 -3 k 6- Yo f- / TO INDICATE D CORPORATION a INDIVIDUAL I=PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O ) GAS STATION 2 DISTRIBUTOR O */ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfional) RESERVATION 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) r /y- 3Y - oS / PHONE A WITH AREA CODE NIGH S: NAME(LAST,FIS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PH Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa bindwaze INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY O CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY .CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS- ✓ boa biodbalb O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME- STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ --4 41 V I j V. PETROLEUM UST FINANCIESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED ✓ bm bindkab EY I SELF INSURED E-1 2 GUARANTEE 3 INSURANCE n 4 SURETY BOND =5 LETTER OF CREDIT [--]6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[Pill II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURIISDIC�TION' At FACILITY# A Tc. N, !e/ i3iylET -- --- LOCATIONCODEOPTI---ONAL iCENSUS TRACT# -OP ONAL SUPVISOR-DISTRICT CODE -OPTIONAL 01 13Yo 37,3 G) 3/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. FORMA(I291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • � FOR6013AP6