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! 0 STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILRY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBA OR FACILITVjJAMg NAME OF OPERATOR ADDRESS NEAREST CROSS STREFF P/JICEL ryOPFpNAq / 6,7 — CITYNAME STATE ZIP CODE ITE PHONE#WITH AREA CODE �v��To CA �7S?ac� 9aZ-/2zz T NdOX C TE 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' Q STATE-AGENCY' O FEDERAL-AGENCY' If owner d UST la a public agenty, DISTRCTS' co Ids the foowinB:name Survkar of d"lon,section. m aaice which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#rapjktw) O 3 FARM Q 4 PROCESSOR = 6 OTHER O RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) .�PHp/NES#WITHAREACODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME Apo eCARE OF gRESS INFORMATION 'vy� t C%4 dy /�oE MAILING OR STREET ADDRESS I'bos blMkaN Q INDIVIDUAL Q LOCALAGENCY STATE-AGENCY CrTy // �-�• - ✓� Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAILAGENCY �y STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME qF OWpIER CARE OF ADDRESS INFORMATION 71p MAILING OR STREET ADDRESS' O ,,Y / p ✓ bmbidkme Q INDIVIDUAL 0 LOCAL-AGENCY Q STATE AGENCY //f+ �'�' I�/V 5/Y( /Xi✓ 0 CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERALAGENCY CITY NAME � 1STATE:54 ZIP CODE PHONE#WITH AREA CODE 6 ��j�C1� 9rrn . 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 METHOD(S) USED ✓ box biMicale D I SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 1J 4 SURETY BOND Q 5 LETTER OF CREDIT 0 6 EXEMPTION O N 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 60%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ IL❑ 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 B SIGNED) OWNER'STRLE DATE MONTWDAY%EAR LOCAL AGENCY USE ONLY COUNTY# JURImSDICTIIOON# FACILITY 83 b� m a 3 LOCATK)N CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVLSOR-DISTRICT CODE -OPTp/YA/. C7Z' '2e io as 9` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE W SITE momfATION ONLY. FORMA 1393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEAENTING THE UNDERGROUND STORAGE TANK REGULA71M • 0 FOR0033AJD