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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s d� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >s - COMPLETE THIS FORM FOR EACH FACILITYISITE re MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-JUST BE COMPLETED) DBA O FACILITY NAME NAME OF OPERATOR - ADDRESS NEARE CROSS STREET PARCEL&(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE x CA 9FA§73A6 ✓BOX Q CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS Nownwol USTBapatAoagwq,m VIetelhelollowh,g re olsllpervisorof4N6!Dn.asd'NnorolruwhchopMaslhe UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = RESE.1IF INTDIAN ION N OF TANKS AT SITE E.P.A. I.D.X(optional) ❑ 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) P6;Q ONE k WI AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Q g� -Z/Z Ild NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFO) NAME CARE OF ADDRESS INFORMATION vG4v� j��`7 MAILING OR STREET ADDRESS INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY d,w r E3 CORPORATION 11 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE -l PHONE a WITH AREA CODE 49 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOF WNER CARE OF ADDRESS INFORMATION MAIL. STREET ADDRESS � .1Oox 1°n6rala O INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY d0,0, )RT �J' T l=CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NA STATE ZIP CODE PHONE N WITH AREA CODE . ;oo -Z�P IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Wx to iM 10 1 SELF-INSURED =2 GUARANTEE =31NSURANCE Q 4 SURETY BOND =5 LETTEROFCREDR =6 EXEMPTION L-1 T STATEFUND Q ESTATE RIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O NOTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH,DAYNEAR LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R FACILITY £T I LOCAOTION CODE -OPTIONAL CENSUBTRACT�OPiIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �T �d`r/ I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFvm INF RMATION ONLY. OWNER MUST FILE THIS FOF TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR' ')STORAGE TANK REGULATIONS FORM A(6.95) 411111110, 111011