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STATE OF CALIFORNIA ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE - in MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITc• 'o^ u ONE ITEM CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME Airport Shell NAME OF OPERATOR ADDRESS lick SOyal 1313 1. Charter lay NEAREST CROSS STREET PAi CEL#OPT ONAL) CITY NAME Air ort la StOCAtca STATE ZIP CODE SITE PMONE#WITH AREA CODE I BOX �}r, CA 951D5 109-9lS-1315 TO INDICATE AUORPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' DISTRICTS =1 tl (]FEDERAL-AGENCY- ' oxvwrdllSTkapWSe .CmVMeNefobwi2W T"""d SEMM"" WWI Section 0TOIX0*hch OPnMa the UST_ TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN MOF TANKS AT SITE E P.A. I.D.R Ilggiwao Q 3 FARM ❑ 4 PROCESSOR 0 5 OTHERaOq TESERVRUST LA ION 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FITmAlda PHONE k WITH AREA Cfrishaft ODE NIGHTS: NAME(LASTFlRST) PHONE#WITH AREA CODE NIGHTS: NAMELAST, RS ( T) PHONE Y WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION E DD , LLC Aura Hattie MAILING ORRISTREET EDAADDRRESESSSE5 ✓ bocN Mo#N ED NDMWAL 0 LLOCAL-AGENCY OI 08CORPORATIONO STATE-A-AGEN CIN NAME 0 PARTNERSHIP OCOUNTY-AGENCY (] FEDERAL-AGENCY STATE ZIP CODE PHONEM WITH AREA CO DE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 101111,01 EITIIp1ISIS, LLC Aura Hattie MAILING OR STREET ADDRESS ✓ box to Wimto 0 INDNIDUAL O LOCAL-AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP =COUNTY-AGENCY FEDERAL.AGEI C1' CITY NAME STATE ZIP CODE PHONE k WITH AREA CODE vAtTrur, 1 0495% 015-404-401a IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- 40 3 9 0 1 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Wx to iWi=a I SELF-INSURED =2 GUARANTEE O 3 NSURAWE =4 SURETY BOND O 5 LETTEROFCREDIT =a EXEMPTION I=7 STATE RIND O8STATE FUND BCHIEF RNMCIALOFFICER LETTER 09 STATE RIND 5CERTIFICATE OFDEPOSn O10LOCAL GOVT.MECHANISM O99OTHER 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.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUE AND CO RECT T O R5 NA D 8 5 NA TANK O R'S TITLE // DATE /MID AY LOCAL AGE CY US NLY 0 COUNTY a JURISDICTION a FACILITY a mLS1`7 Lf 1 d 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)