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pW^ C �� e STATE OF CAUFORWA �� 0 STATE WATER RESOURCES CONTROL BOARD W UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :�� COMPLETE THIS FORM FOR EACHFACILITYISfTE C'lpO^"'� MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSEDSITE ONE REM O 2 INTERIM PERMIT F_� 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE —' J I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) nPA ORF CIU NAM NAMEOFOPERATOR CQ oi- ADDRES - NEAREST CROSS STREET PARCEL#(OPTIONAL) 2 ti ScAcvum S# Y2 CITY NAME I STATE ZIP CODE 'SZy SITE PHONE#WITH AREA CODE IN,J CA ✓ BOX CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' O STATE AGENCY• O FEDERAL-AGENCY' TOINDICATE DISTRICTS' 'If owner of UST Is a public agency.complete the following:name of Supervisor of dNicion,sedan,or office which operates the UST TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aptionap RESERVATION 0 3 FARM 0 4 PROCESSOR � 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS:- AME(LAST,FIRS . HONAREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE i �rcH 2):! l -3Z 8 NIGHTS: NAME(LASt,PIRST) ONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE itITH AREA CODE Sa^\.t- 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME • CARE OF ADDRESS INFORMATION �wk�•�-Y-� P�-�11,;�.. Teas. ' MAILING OR STREET ADDRESS ✓ box to Micate INDIVIDUAL LOCAL STATE AGENCY (b (1 A- `,_` 3 0 r54CORPJRATION PARTNERSHIP 0 COUNTYAGENCY FEDERAL AGENCY CITY NAME �� STATE 21P CODEPONIWITf�RE' 3CODE QZv? mr III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION S MAILING OR STREET ADDRESS ✓ bot biMicate O INDIVIDUAL LOCAL AGENCY =1 STATE AGENCY O CORPORATION PARTNERSHIP COUNTY AGENCY 0 FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE Jr WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F41 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMkals 5<1 SELF INSURED 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND 1:1 5 LETTEROFCREDT O 6 EXEMPTION 0 93 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.5�' III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OW ENAME R'S NAM PRINTED&SIGNED) OWNER'S TITLE DATE MONTHVDAYNEAR LOCAL AtENCY U ONLY COUNTY# JURISDICTION# FACILfTY#QD 7S/p 7 m a 3 4 / 5 0 (0 -713 1016*v'er7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ?zd 6 i, q7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITEINPOWMIT1611 ONLY. OWNER MUST FILE THIS FORM WITHIt THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUTORAGETANK REGULATIONS FORM A(393) FORDP33AA7