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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 8m e COMPLETE THIS FORM FOR EACH FACILITY/SITE m ' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -- I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR CILITY NAME NAME OF OPERATOR To F AVRES NEARES CROSS STREET PARCEL#(OPTIONAL) CRNAME • Yr+ / . ff STA 7E LP�ODE� SITE PHONE M WITH AREA CODE ✓BOX Q CORPORATION O INDIVIDUAL O PARTNERSHIP ED LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS Nownwof UST u e xbll apref c mMMe the fokwina rem,d suIrervisorof division.s¢0on or office AtIr operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN 1#OFTANKS AT SITE E P.A. I.O.#(cpf ov ao 01 RESERVATION ❑ 3 FARM ❑ d PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#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 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION OCCcv SQ4t&-rF MAI NG ORTRE ADDRESS ✓ bnabnRrMe Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY ERr CORPORATION O PARTNERSHIP Il COUNTY-AGENCY Q FEDERAL- AGENCY CITY NAME /1 hQy=/ f STATE LP CO�E PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) G NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ 0oxmmtl 6 Q INDMDUAL LOCAL-AGENCY 0 STATE-AGENCY CORPORATION =PARTNERSHIP O COUMY-AGENCY D FEDERAL-AGENCY CITY NAME STATE 21P CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 5-R- -FELEEEI V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓b°,N�, O I SELF-NSURED O 2 GUARANTEE =3 INSURANCE O#SURER BOND 0 5 LEfTEROFCREDR O 6 EXEMPTIONO T STATE FUND (]8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER OBSTATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O88OTHER 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: L❑ 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&SIGNATURE) TANK OWNER'S TITLE DATE MONTIVDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 7 FT7 I I Z L31 LOCATIONCODE-OPTIONAL CENSUS TRACT# -OP NALSUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(6-95) OWNER MUST FILE THIS FORT 'rH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRIL" 'I STORAGE TANK REGULATIONS