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i STATE OF CALIFORNIA +� STATE WATER RESOURCES CONTROL BOARD s ° UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A COMPLETE THIS FORM FOR EACH F RYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAOR FACILITY NAME NAME ` � NAME OF OPERATOR ADDRESS �y //L/ NEAREST CROSS STREET PARCEL#IOPrpNAU r CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S/v cl A TOINp RATE O CORPORATION O INDIVIDUAL PARTNERSHIP DISTRICTS COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATCN 3 FARM ❑ 4 PROCESSOR 5 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) sK K NIGHT�AST,FIHST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME /L 1 O `G _ CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS F ✓ box bintlxou INDIVIDUAL LOCAL AGENCY (]STATE AGENCY Los- x A-4 jar (]CORPORATION PARTNERSHIP E-1 COUNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS Wx WiM ab E=j INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY CORPORATION [_1 PARTNERSHIP Q COUNTY-AGENCY O FEDERAL#GENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. TY(TK) HO L4E-I-Cl l_3I_C_I%I;,U l V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bintlbab 0 1 SELF-INSURED 0 2 GUARANTEE i= 3 IN ANCE O 4 SUR Ett BOND (] 5 LETTEROFCREDIT 0 6 EXEMPTION 99 OTHER 71 VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is the d. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ 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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY 3`70C> COUNTY# JURISDICTION# FACILITY# SN6/A/ O3 LOCATION CODE -OPTIONAL ICENSUSTRACT# -OPTIONAL SUPVISOR-DISCT CODE -OPTIONAL V 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 -� FORW33A R6