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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 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 oa I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) NAME OF OPERATOR DBA OR FACILITY NAME �^ ,C S� /�Q✓GL4C�LGr e"rNEAREST CROSS STREET PARCEL#(OPTIONAL) ADDR SSs-f'.c�G, ��V•a T. CITY NAME STATE ZIP CODE SITE PHONE p WITH AREA CODE CA ✓ BOX CORPORATION ED INDIVIDUAL O PARTNERSHIP DISTRICTS LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE Honer of USTis a pubho agency,complete the followng:nems d supernsord division,section oro#Ice which Wetetes the UST TYPE OF BUSINESS ❑ 7 GAS STATION ❑ 2 DISTRIBUTOR RESEIRVATION #OF TwAN�KS AT SITE E.P.A I.D.#(optional) ❑ 3 FAFlM 4 PROCESSOR ❑ 5 OTHER ORTRUST LANDS 4'- EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AR CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE qfjit 3� - NIGHTS: NAME(LAST,FIRST) PHON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING OR STREET RES$ ✓ box to mdcele OINDIVIDUAL OLOCAL-AGENCY [::iSTATE-AGENCY /C7, !� r._,-,.^' a CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY�AM GSTATE ZIP CODE P ONE#WITH AREA CODE 4 9*zd/o Ev all 3f,-7- ,/0,1 r III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME OF OWNER MAILING OR STREET ADDRESS ✓ boxto sMsate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY Q CORPORATION O PARTNERSHIP O COUNTY-AGENCY Q FEDERALAGENCY l` STATE ZIP CODE PHONE#WITH AREA CODE CITY NAME ;•' 4 Y�- 1 ;•T IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 -Lbw V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Ear to indicate0 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND O 5 LETrEROFCREDIT O 6 EXEMPTION O]STATE FUND O B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =6 STATE FUND&CERTIFICATE OF DEPOSIT O to LOCAL GOVT.MECHANISM O 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: I.❑ II. It.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TMONTHIDAY/YEAR TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DAE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# C'r' LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVIBOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT 4 ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR jWH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*STORAGE TANK REGULATIONS FORM A(6-95)