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a STATEOFCALIFORNASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SRE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME `a r NAME OF OPERATOR NEARESTCRO ADDRESS STRE T PARCEL (OPTIONAQ �.�. CITY NAME.,�,I�..�•� � STATE ZIP CODE CA �S2.�D SITE PHONES WITH AREA CODE Box TOINDC TE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL AGENCY ED COUNTY-AGENCY• Q STATEAGENCY• If owner of UST Is a public agency,wntolate the following:name of Supervisor of UNbbn,aeclbn,DISTRICTS office ' operates the UST TYPE OF BUSINESS a t GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.a(qor—al) 0 3 FARM O 4 PROCESSORESERATION 5 OTHER OR TRUSTVLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional 11 DAYS: NAME(LAST,FIRST) PHONE a/WITH AREA CODE DAYS: NAME(LAST,FIRs1) T'/ pl�q—�ZL PHONE♦WITH AREA CODE NIGHTS: NAME(LAST,FIgST) P NE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME �, /� CARE OF KESS INFORMATION CSI-- �D.G/= y �Y� MAILING OR STREET ADDRESS �(3�✓pow b Intllcale O INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY CITY NAVE CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERALAGENCY ST TE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER d•. CARE OF ADDRESS INFORMATION M ING OR STREET ADDRESS 11pow birdkye K�SA1I 3Z—i-14, � INDIVIDUAL 0 LOCALAGENCV STATE AGENCY CITY NAME / O CORPORATION O PARTNERSHIP Q COUNTY AGENCY FEDERAL AGENCY STATE ZIP CODE PHONE N WITH AREA CODE GDS ..o G+E t� 9CJ�i IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO r4]4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓hovbiMbate 1 SELF INSURED =2 GUARANTEE EA 3 INSURANCE O 5 LETTEROFCREDIT I=6 EXEMPTION /SURE BONG 59 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. 11 II.O III. 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 MONTWOAY/YEAR LOCAL AGENCY USE ONLY COUNTY u JURISDICTION x FACILITY e LOCATI NCODE -OPTIONAL CENSUS TRACT;1 -OPT/ONAL 9UPVISOR-DISTRK:T COOS -OPipNAL r✓ - ,}-GG — THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0