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r ,era e, STATE OF CALIFORNIA o.� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e e I�Oe M� COMPLETE THIS FORM FOR EAC SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO$ SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA O FACILITY NAME /7p NAME OF OPERATOR C4 � Ce.n }-rc, I L O✓I'S CGT)Z--:9 ADDRESS nn n NEAREST CROSS STREET PARCEL#(OPTIONAL Ill S1�StJ 1` cx j' MCD-A-1 CITY NAME STATE ZIP CODE S TE PHONE#WITH AREA CO DF. CaV BOX SzOS 66 -9 X31 TO INDICATE O CORPORATION E-1 INDIVIDUAL O PARTNERSHIP [�j LOCAL-AGENCY D COUNTY-AGENCY STATE-AGENCY FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN IS OF TANKS AT SITE I E.P.A. 1.D.#(oplionao RESERVATION 2 O 3 FARM O 4 PROCESSOROTHER OR TRUST LANDS J EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) - PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION sr—mc— MAILING OR STREET ADDRESS ✓ box blMbale D INDIVIDUAL E::] LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION ED PARTNERSHIP couNrY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION --'Q h'1 MAILING OR STREET ADDRESS ✓ box birxlkale INDIVIDUAL LOCAL-AGENCY L1 STATE AGENCY O CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO 1744]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate L1 1 SELF-INSURED l= 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND E=1 5 LETTTROFCREDIT l=6 EXEMPTION %OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Ezf it.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHLDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3 9 Zl_J 311171 Z Y LOCATION CODE OPTIONAL CENSUSTRACT# -OPTIONALISUPVISOR-DISTRITCODE -OPTIONAL �� ZZ —2—`73 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • • 3AA6