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STATE OF CAUFORNU, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE p 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIU NAME /J NAME OF OPERATOR j ADDRESSI NEAREST CROSS STREET PARCEL#(OPTIONAL) ZiG, n Ta S'T , / CITY NAME STATE ZIPS.DDJF-� ./v SITE PHONE#WITH AREA CODE CA y ✓BOX O CORPORATION O INDNIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS I oxnerol UST Is a public agency,complete IN lolbWng rome of supernsorol dbison,sedan or otr"•Nii operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE EIRVATION #OF TANKS AT SITE E.P.A. I.D.%(optional) ❑ 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME OAST,FIRSTT� ^-/� jPHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME �� / O CARE OF ADDRESS INFORMATION MAILING OR STREETADORESS ✓ Lox la m6cate Q INDIVIDUAL O LOCALAGENCY O STATE-AGENCY O CORPORATION =PARTNERSHIP D COUNTY-AGENCY DFEDERAL-AGENCY CITY NAMEl 1„ STA7� ZIP CODE, �H( €UZ11H ZEA / E _ I l ( / ) III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER - CARE OF ADDRESS INFORMATION moi/ Y".'� ✓1i!s f MAILING OR STREET ADDRESS ✓ box londirale OINDIVIDUAL OLOCAL-AGENCY QSTATE-AGENCY Q CORPORATION Q PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to inkals 1 SELF INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND Q 5 LEITER OFCREOT 0 6 EXEMPTION "T STATE FUND Q 6 STATE FUND B CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND B CERTIFICATE OF DEPOSIT = 16 LOCAL GOVT.MECHANISM 1� 99 77 ER Vl. 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: 1.❑ 11.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED 8 SIGNATURE) TANKOWNER'STITLE DATE MONTH/DAY/VEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORNr THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWRAGE TANK REGULATIONS FOR?A(6-95)