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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �y"'BB o°o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .A ° COMPLETE THIS FORM FOR EACH FACILITY/SITE Itl' ' , MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY AM r AME OF OF ERATOR ADDRESS i+ J' NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME GTACEA ZIP COD5e5e^ } SITE PHONE AREAE_ a YS ✓BOX CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL.AGENCY' TO INDICATE DISTRICTS 'dwerof USTisapublic agency,complete the lolbwing.Icon ol supervisord division,section oro#ke%0,0 operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A I.D.#(Wtionao RESERVATION 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 71 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME �'� CARE OF ADDRESS INFORMATION MAILING OU�ET DRE j.J_ ✓ WsN°U�e D INDIVIDUAL OCAL-AGENCY STATE-AGENCY .JJjj CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE- ZIP COD E^ ,� -76 PHONE#WITH AREA CODE III. TANK OWNER IN ATION-(MUST BE COMPLETED) C'fl� 7�YS NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESK ✓ bos to ndicote 0 INDIVIDUAL LOCAL-AGENGY Q STATE-AGENCY S (6111d CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL AGENCY CITY NAME SVLTE ZIP COD ^ PHONE#WITH AREA CODE IV. BOARD OF EQUALIZ ION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ben 10 inSloete 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE O 4 SURETYBOND Q 5 LETTEROFCREDIT O 6 EXEMPTION =]STATE FUND � 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE RIND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 99 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: 1.❑ It.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANKOWNER'S NAME(PRINTED&SIGNATURE) TANKOWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY M m T5Y pc=sirivi LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 4,1 17P 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 FOF ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGF 3 STORAGE TANK REGULATIONS �� FORM A(6.95) 1.4w