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1. '"60Ue e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD T UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A n 's COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY r,71 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SI ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBACORFACILITY NAME NAME OF OPERATOR I 1 �w�-rr-zu I ADDRESS NEAREST CROSS STREET PARCEL*(OPTIONAU Lj K114 0L CITY NAME STATE ZIP CODE InE P ONE#WITH AREA CODE at— !S L!S n CA TOINDICATE CORPORATIONINDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY COUNTYAGENCY' O STATE-AGENCY' O FEDEMLAGENCY' STI X DISTRICTS' N owner d UST Is a public agency,mnplets the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.At(optional)0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR RESERVATION EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE c _ NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED W67 CARE OF ADDRESS INFORMATION A4 YC:e MAILINGORSTREET RESS ✓ boa 10 indicate INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY LJ D CORPORATIONPARTNERSHIP O COUNTY-AGENCYO FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE C III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION S ACDF N MAILING OR STREET ADDRESS ✓boa b indicate INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION PARTNERSHIP O COUNTY-AGENCY E::] FEDERAL AGENCY CITU NA r�' STAT WITH ZIP CODE 0# q5�� I PHONE# TH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa bindcale t SELF-INSURED Q 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND O 5 LETTEROFCREDIT O 6 EXEMPTION S 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 OWNER'SNAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTWDAYNEAR 9 A) T 3e qc LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# m 'z -5 1 i I LOCATION CODE -OPTIONAL CENSUS TRACT# -OP77094L SUPVISOR-DISTRICT CODE -OP77ONAL THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION- FORM B,UNLEIS IS A CHANGE OF SITE INFORATION MONLY. OWNER MUST FILE THIS FOR rH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO , ,STORAGE TANK REGULATIONS