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exe < _, 9 STATE OF CALIFORNIA ."WA g STATE WATER RESOURCES CONTROL BOARD W uqg UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A >- i COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA RFACILITYNAME NAMEOFOPERATOR ADDRES NEAREST CROSS STREET PARCEL 9(OPTIONAL) CITY NAME STATEZIP CO E ITE PHONE i WITH AREA CODE To ] CA � 656 ZoR 7 s - 2TZc ✓ WXCORPORATION O INDIVIDUAL PARTNERSHIP LOCALAGENCY O COUNTY-AGENCY' O STATE AGENCY' L FEOEML#GENCY' TO INDICATE DISTRICTS' N owner of UST Is a public agency,complete the following:name of Supervisor of d"on,section,or office"Ich operates the UST TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ' IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.a(op(iaup RESERVATION 3 FARM 0 4 PROCESSOR = 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAVE(LAST,FIRST) PHONE i WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE v 369- 7/7 'V� 'Q0 /�DIJ C/ 36 -7i7 NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PH O WITH AREA DE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILINd OR STREET ADDRESS ✓ boxiolydkaU EnNDIVIDUAL O LOCALAGENCY =STATE-AGENCY Q BO O CORPORATION O MTNERSHIP COUNTYAGENCY O I'MERAL-AGENCY CITY NYE STATE ZIP CODE PHONE WITH AREA OE / /o c75686 Vcf J 79� -Z 7ZC) III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOF WNER CARE OF ADDRESS INFORMATION MA IN ORST/nR�EETyAODRESS ✓ �x bindNtle INDIVIDUAL 0 LOCALAGENCY STATE-AGENCY a - ✓c/` CORPORATION ARTNERSHIP 0 COUNTY AGENCY Q FEDERALAGENCY CITY N ME STATE ZIP CODE PHONE 4 WITH AREA CODE 95686 0 79 -Z7Z4�, IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ bOxbiMioak E::] I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND O 5 LETTER OF CREDIT 6 EXEMPTION D 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.O I.0 III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNE R'S NAME(PRINTED 6 S IGNED) OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY x JURISDICTION a FACILITY# I TTT7J6 LOCATION CODE -OPTIONAL CENSUSTRACT -OPTIONAL 9UPVISOR-DISTRICT CGDE -CPTpNAL TWS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE 11FORMATKIN 0 Y. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A ISM) I FOR0W3Ni7