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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EACH FACILITYISITE rn MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED. ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR ACIUTY NAME NAME OF OPERATOR Ii YV6d,-*G e5c0G7Ad!::- AL-1 AODRF NAME / NEA SSTREET O PARCELX(OPTIONAL) CITY 77VVMs�'/G STACA /ZIPSITE PHONE R WITH AREA CODE ✓BOX % O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS X ovmerol UST's a public agency,=plate the folbwhtg:re ecfsWervSoroldNisbn,seclbnorafte ichopeatesthe UST TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR ❑ RESEIRVAT10N R 01-TANKS AT 517E E.P.A I.D.X(optiOneQ = 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAM(LAS,,FIRST) #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHOrITHTH NE#WAREA 4/C+OD'yEge NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) ' (1 �E �, CARE OF ADDRESS INFORMATION G4s-,Q�nY-/ (Jf 'i t MAILI OR EETAODRESS ✓ boxto eiCxate INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY . 0 CORPORATION PARTNERSHIP (] COUNTY-AGENCY El FEDERAL-AGENCY CITU NAME STr� Z� 9E p�lO H D^Vi(I �� (pOE./'.#L el— III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OWNER CARE OF ADDRESS INFORMATION MAILI OR STREET AD RESS ✓ box to indbale Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY ' �. CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAMEE STATE ZIP C 2q ,r PHONE#WITH AREA CODE / Jh 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 METHOD(S) USED ✓bax to indicate 1 SEF-INSURED O 2 GUARANTEE 0 3 INSURANCE E:1 4 SURETY BOND 0 5 LETrEROFCREDIT =a EXEMPTION (-17 STATE FUND �8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0990THER 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.❑ 11.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHfDAYIYEAR LOCAL AGENCY USE ONLY COUNTY% JURISDICTION# FACILITY% m F77_1 % J� LOCATION CODE -OPTIONALCENS ST CTM -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL 5v -rho 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 FORIW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO0STORAGE TANK REGULATIONS FORMA(6-95)