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4au r STATE OF CALIFORNIA e� STATE WATER RESOURCES CONTROL BOARD F 6 a o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � COMPLETE THIS FORM FOR EACH FACILITYISITE °4i%wont", MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF CIL1TY NAME NAME OF OPERATOR ADDRESS NEA EST CROSS STREET PARCEL 0IoPrIONAL) CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE V 1� CABox TOINDICATE D CORPORATION []INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY STATE•AGENCY' Q FEDERAL-AGENCY' DISTRICTS' If owner d UST is a public agency,complete the f0lowing:narm of Supervisor o1 d"ion,section,or office which operates the UST TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR ❑ RESERVATION OF TANKS AT SITE E-P.A. I,D.a(01171-1) 0 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DNAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE AYAG -9 NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAM ( T,FI(U) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NA E CARE OF ADDRESS INFORMATION MAILII Q OR STREET ADDRESS ✓ box toindicatsINDIVIDUAL = LOCAL-AGENCY STATE-AGENCY _E - Q �l 7 O CORPORATION TNERSHIP = COUNTY-AGENCY (] FEDERAL-AGENCY CIJY NAME STAT ZIP CODE PHONE WITH AREA 90DE Ill. TA ORMATION-(MUST B ETED) NA NER CARE OF ADDRESS INFORMATION C(,� G'6 � MAILIN0,0R STREET ADDRESS ✓ box 1olndiicM INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY =CORPORATION = ARTNERSHIP = COUNTY-AGENCY © FEDERAL-AGENCY CITY NAME ST TE ZIP CODE PHONE a WITH AREA CODE I �HQ4 LiZATION AGE FEE ACCOUNT NUMBER-Call(916)322 96 sf gUesiions arise. TY(TK - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b indicate I SELF-MURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND S LETTER OF CREDIT Q 6 EXEMP71ON 0 99 OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checke . CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ fl,❑ Ill. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNW LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY# E�7 I I V e> LOCATION CODE -t7FT10NAt ICE SUUS`TRACT a -OPTIONAL SUP��A�-DISTRICT CODE -OPTIONAL ,.-^T': z � yrs 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 A(3193) 0 0 (�41 ��t�} FOROMA-R7 y�,)I