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• • STATE OF CALIFORNIA e STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE z ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �J I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / � � NAME OF OPERATOR ADDRESS / 7/•1/ NEAREST CROSS STREET PARCEL#(OPTIONAL) ,?70-7 00�-700-0 CITY NAME( STATE ZIP CODE SITE PHONE x WITH AREA CODE CABOX �SGS6 TO INDICATE O CORPORATION D INDIVIDUAL f]PARTNERSHIP DS RICTSENCY COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ REV IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.A(optimal) 3 FARM 4 PROCESSOR d5 OTHER OR TRUST LANDS 3 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) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓box bintlkate E�j INDIVIDUAL. 0 LOCAL-AGENCY Q STATE-AGENCY p, J��X_ ITjS 0 CORPORATION I� PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY C 7 / YTI /!!] STATE- ZIP LADE �� PH�O'INE#W�TFiG/ACODE �7�`j III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ��/TT _ / NAME OF OWNER T CARE OF ADDRESS INFORMATION MAILIINNC��OR STREEET/A/ADDRESS• // ✓ Eox birltlicaN INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY • U, /30vo"Z 9g - 0 CORPORATION PARTNERSHIP D COUNTY-AGENCY = FEDERAL AGENCY CITY N/ 1 -� �- STAT 23Pg� l�� HONC.S WIT-H�AREA DE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323V-9555 if questions arise.\/ / A Z TY(TK) HQ 14141-F] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindkale 1 SELF-INSURED 2 GUARANTEE =1 3 INSURANCE 4 SURELY BOND D 5 LETTEROFCREDIT O 6 EXEMPTION El W 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. .❑' 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) APPLICANTSTITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION# FACILITY# �' I FuuG 8� LOCATIONCODE OPTIONAL ICENSUSTRACT#„OPTICNAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BBYY AT LEAA_SVT(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, FORMA(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 FOR0037A-R6