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STATE OF CAUFORNA ^� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACHFACILITYISITE MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA O�CI ITY NAME NAME OF OPERATOR I/ , y A RESS NEAREST CROSS STREET PARCELO(OPTIONAU . • � - IJi�Y CITU NAI.)E�Ap STATE ZIP CODE /r(1'I SITE PHONEi WITH AgEA CAGE CA TO INDICATE ATE O CORPORATION D INDIVIDUAL 0 PARTNERSHIP Q LOCAL Q COUMY-AGENCY' D STATEAGENCY' 0 PIECE If ff canner of UST Is a Public DISTRICTS' p agency,mnplele the following:name of Supervkor of dHbion.e6ChOn,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN i OF T AT SITE E.P.A. 1.D.i(golianary 3 FARM O 4 PROCESSOR tct OTHER OOR TRUSTVLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION U Gz7 �� Y�4,4 MAILING OR STREET ADDRESS ✓ boa bindbale O INDIVIDUAL E-1 LOCAL =STATE-AGENCYENCY Z05,3 D_ CORPORATION PARTNERSHIP Q COUNTY AGENCY = FEDEMLAGEN CV CITY NAME f5wqAT ��M1 STAT ZIP CODE HONE i y+ITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEO=vG& _„ ^ CARE OF ADDRESS INFORMATION �'/rE`Y'/Y•4,< MAILING OR STREET ADDRESS ✓ boxbiMicate / -5 3f- A/�/'v.�`�' ,�/ „}1 I� INDIVIDUAL Q LOCA6AGENCY = STATE AGENCY CITY NAME ��'O' LY CK> CORPORATION � PARTNERSHIP � COUMRAGENCY 0 FEDERAL AGENCY 1 �• STA ZIP CODE HONE-I. TH AREA CODE 9 r ' 67Fr� 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 ✓box b Indicate 1 SELFINSURED 0 2 GUARANTEE 1:13 INSURANCE O 5 LETTEROFCREDIT =6 EXEMPTION Oa- O A SURE YBOND Oa-99 w OTHEfl U 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,O 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 8SIGNED) OWNER'S TfrLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION• FACILITY It p /Z gy LOCATgN CODE -OPTIONAL CENSUS TRACTi -OPTIONAL 9UPVLSOR-DISTRK1COOE -OPTIONAL z3- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE MAT"0 T OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO _ \1Y�l h FORMA(3q3) • • FOR6033A.f0 y �