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STATE OF CALIFORNIA e STATE WATER RESOURCES CONTROL BOARD + II u UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 's COMPLETE THIS FORM FOR EACH FACILRYISITE a�(POPY�� MARK ONLY T NEW PERMIT 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO — ONEITEM E::] 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) DBAORF ILITYN E NAME OF OPERATOR -An ADDRESS NEAREST CROSS TREET PMCEL a(OPTX)NAU CITV�E O Ary{ STATE ZIP CODE SITE PHONE a WITH AREA CODE CA BOX TOINDICATE y5rl CORPORATION �INDIVIDUAL l�PARTNERSHIP LOCALAOFNCY �MY.AGENCY• 0 STATE-AGENCY' 0 FEDERAL-AGENCY' N owner d UST N a 4b DISTRICTS p agenq,mnplele IM idlawaN:name d Supervisor 01 tlNYbn,eeetbn,m olio which operates the UST TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN 19OF TANKS AT SITE E.P.A I.0.e(tgbnag RESERVATION 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS' NAME(LAST.FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE C�PU9 - 02 NK94TS:NAME(LAST.FIR T) ,PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ EssbINSCAR [:3 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 0 CORPORATION O PARTNERSHIP 0 COUNTYAGENCY D FEDERALAOENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box birtlba4 0INDIVIDUAL =1LOCAL-AGENCYSTATE-AGENCY D CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-[4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOO(S) USED ✓ Ear biMkale 0 I SELF-INSURED 0 2 GUARANTEE n 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDT 0 6 EXEMPTION = N 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.O if.O III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHOAY/YEAR LOCAL AGENCY USE ONLY F—C. $D Vf t f COUNTY# JURISDICTION• FACLITY* lalil 10161 m 3 LOCATION CODE -OPTIONAL CENSU�STTRA=CT a.oPP�TIONAL SUPVISOR.DISTRICT CODE - "CAUL 61 1 C� ✓ O ✓ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM AAr4l" 1 _ p I V L/) (P / tC-l' �iLC.2l� GLU.`li- r L �LF-I �C.f-Ys'L-Ct✓4-lC'. FORamlbg9 Af aelmd,