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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A 0 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR F�NAME NAME OF OPERATOR a A DRESS NE�A/R�ES/TCCROOSS TRE, , I PARCEL#(OPfIONAU CITY NAME STATE ZIP CooF_ SITE PHONE At WITH AREA CODE �n CA qv )tet - zzZ TO DIOX RTECORPORATION Q INDIVIDUAL 0 PARTNERSHIP l� LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' N owner d DISTRICTS'UST le a public ,complete,the 1011mirp:nanw of Supervisor of tlNlson,Becton,Of office which operates the UST TYPE OF BUSINESS O t GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN 10 OF TANKSAT SITE E.P.A. I.D.#(ap(Axraq ❑ 3 FARM Q 4 PROCESSOR 0 5 OTHER ORESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION T MAILING OR/STREET ADDRESS `+V ✓hor/b-Ul/ndkme Q INDIVIDUAL O LOCAL-AGENCY 0 STATE-ArENCY ED CORPORATION O PARTNERSHIP lD COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME, ST I ZIP CODE I PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ' ^ 1 Q ✓ beX blydlcale 0 INDIVIDUAL 0 LOCAL AGENCY [71 STATE AGENCY CORPORATION O PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STA ZIP CODE PHONE#WITH AREA CODE 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 ✓boa to Weals O t SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE D 5 LETrEROFCREDIT O 6 EXEMPTION 0 93 OTHER SURETYBOND 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 TINE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHIDAYNEARI, LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Of FACILITY# LO Oy- CODE -OPTIONAL CENSUS TRIC"TIONA, SUPVISOR-DISTRICT CODE .OPnONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNJORAGE TANK REG TIONS FORM A(393) l FOR0033AA7 Y13�