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p,oUR f4 STATE OF CALIFORNIA t c°s STATE WATER RESOURCES CONTROL BOARD 3 p.� o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY r j 1 NEW PERMIT 3 RENEWAL PERMIT ��I 5 CHANGE OF INFORMATION _ 7 PERMANENTLY CLOSED SITE ONE ITEM j_J 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME�s NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S/, "/41-111 CA ✓ BOX _ TO INDICATE _I CORPORATION L-1 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY 11 DISTRICTS TYPE OF BUSINESS 1 GAS STATION [::] 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION —� 3 FARM 0 4 PROCESSOR Ej 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH A NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box ID indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 6-6 -S &/ 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME T STATE ZIP CODE PHONE#WITH AREA CODE / zl_ 04- 2 3-Z> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION !Zee _-,!77 MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY 0 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 14 I-Ld 13L-zrz� V. PETROLEUM UST FINANCIAL SPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ oox to indicate SELF-INSURED L�j 2 GUARANTEE L-1 3 INSURANCE 0 4 SURETY BOND L ,' 5 LETTER OF CREDIT 0 6 EXEMPTION L-1 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 c cked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.F7 II. III. THIS FORM RIAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# `j _ Lei LOCATION CODE OPTIONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 0/ 3 _2' 'C-0 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 /l/ FOR0033A-R6