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0 <6Wn f STATE OF CALIFORNA o f STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE x�renN`� MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT If TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DPA OR FACILITY IN �� / NAME OF OPERATOR ADDR/ESS L 0Y A'�-Z/ f � ! 4�/ - I NEAREST CROSS STREET PMCE NIOPfq AU J /� e CITY NAME LS STATE ZIP CODE SITE PHONE NWITH AREA CODE ✓ BOX CA TOINgCATE O CORPORATION O INDIVIDUAL (]PARTNERSHIP LOCAL-AGENCY COUNTY AGENCY QSTATE-AGENCY' ED 'If owner of UST Is a public agency,complete the following:name of Supenbar of divisbn.section, IS RICTffice whichoperdles the UST If AGENCY' TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A, I.D.♦(gxfbnap 3 FARM = 4 PROCESSOR 5 OTHER O OR TF LANDS , EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY DAYS: NAME(LAST,F CONTACT PERSON (SECONDARY)-optional FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRSn �' lr— PHONE 1'WITH AREA CODE NIGHTS: NAME(LAST,FIRST) r•� PHNE A WITH AREA C'O/DE NIGHTS: NAME(LAST,FIRST) 97 ' PHONE 4 WITH AREA CODE IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME 2U, CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS / ✓ box b Indicate E=1 INDIVIDUAL E-1 LOCALAGENCYC] STATEAGENCY CITY NAME ED CORPORATION O PARTNERSHIP ED COUNTY AGENCY FEDERAL AGENCY GO� STATE ZIP CODE P NE a WITH AREA ODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OFADDRESS INFORMATION MAILING OR S/TREET ADDRESS ✓ box binbbale INDIVIDUAL O LOCA = STATE A CITY NAME Y O CORPORATION O PARTNERSHIP E:1 COUNTY AGENCY f] FEDERAL-AGENCY G�+ STATE ZIP CODE PHONE# ITHAREA ODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. —9�7 TY(TK) HQ 4 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to IMbate I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE I�5 LETTER OF CREDIT O 6 EXEMPTION4 SURETY BOND 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 checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: y� ❑ ❑ TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTYu JURISDICTION I—LTJ # FACILITY III, LOCATION CODE -OPTIONAL CENSUS TRAUzz a .OPTIONAL p SUPVISOR-DISTRICT CODE -OPTpAIAL OO THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SM INFOR(AATjOh ONLY. FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIVORAGE TANK REGULATIONS FORepg3Afl7 •