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STATE OF CALIFORNIA 'E STATE WATER RESOURCES CONTROL BOARD W m n UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Az o COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY IN 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY O SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 5 V` I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITYNAME `/+ A NAME OF OPERATOR �� "' � .�� PMCEIA(OPTIONAL) ADDRESS NEAREST CROSS STREET 2214 �r Za 5 N Zo5-260-1 CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE scat and CA ✓ �% CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE.AGENCY- O FEDERAL-AGENCY' TOINDICATE DISTRICTS' •II owner of UST Is a public agency.cor plate the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.N(option) ❑ ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D YS: NAME(LAST,FIRST) PH NEN WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 3b8_2Z91 NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE•WITH AREA CODE 3 A•1N,c— IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION NUC LOCAL AGENCY✓ box b Indicate INDIVIDUAL C:3 STATE-AGENCY MAILINGOR STREET AD RESS A CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDEMLAGENCY STATE ZIP CODE PHONE a WITH AREA CODE CITY NAME �1 /t �'ZI/•D /� 3(�U-••4-I91 LOO I a l 7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME OF OWNER � ^� MAILING OR STREET ADDRESS ✓ box 0Indkate D INDIVIDUAL D LOCAL-AGENCY �STATE AGENCY— BE GENCY CORPORATION PARTNERSHIP COUNTY-AGENCY E FEDERAL-AGENCY STATE ZIP CODE PHONE A WITH AREA CODE CITY NAME IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)33221669 iifgquoestions arise. TY(TK) HQ 4 4- - p 3 '� 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ tov bindicate t SELF-INSURED Q 2 GUARANTEE 3 INSURANCE O%SURETY BOND (]5 LETTER OF CREDIT O 6 E%EMPTION gg 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'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MGNTWDAY/YFAR 01 - 22-96 LOCAL AGENCY USE ONLY COUNTY IT JURISDICTION If FACILITY!7 LOCATION CODE -OPTIONAL CENSUS TRACTI -OPTIONAL -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE MA ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA1101118 FOROWMA7 FORM A(393) 0 40