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� • • xae .�oa STATE OF CALIFORNIA °otx STATE WATER RESOURCES CONTROL BOARD 3,,,fir UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w _ COMPLETE THIS FORM FOR EACH FACILITYISITE IA a MARK ONLY ❑ 1 N ERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA 09 FACILITY NAME NAME OF OPERATOR 1AA ADDRESS N EST CROSS TR T PARCEL 9(OPTIONAL) uJ r CITY NAME STATE ZIP CODE E PPHHO E#WITH AREA CODE Col cS-f D G Y�✓ BOX E:)CORPORATION ty� INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE.AGENCY' 1`7 FEDERAL-AGENCY' TO INDICATE ' \ DISTRICTS ' Homer of USTls a public agency,complete the forowng:name of sWarvearof division,section or office which operetes the UST TYPE OF BUSINESS T?� ' GAS STATION O 2 DISTRIBUTOR ❑ gEV IF INDIIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) ❑ 3 FARM Q 4 PROCESSOR ❑ 5 OTHER 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 ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE A )141R II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME F CA ADDR SINFORMATION MAILINGORSTREETADDRESS61box to caws INDIVIDUAL OLOCAL-AGENCY OBTATE-AGENCY I�CORPORATION O^PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STAT E ZIP CODE PHONE#WITH AREA CODE Z5+6 G -fr9� H 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoiaiies ll INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE 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 F44- - cry Llu V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indcale M 1 SELF-INSURED 0 2 GUARANTEE [:1 3 INSURANCE M 4 SURETY BOYO [:] 5 LETTEROFCREDIT O 6 EXEMPTION "7 STATE FUND ESTATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9STATE FUND&CERTIFICATE OF DEPOSIT [::] IO LOCAL GOVT.MECHANISM 1= 99 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: L❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAMEPRINTED&SIGNATURE) TANK OWNER'S TITLE I DATE MONTHMAYIYEAR LOCAL AGENCY USE ONLY &C-w ZA3 COUNTY# JURISDICTION# FACILITY 901,70 a3 l 3 � LOCATION CODE -OPTIONAL CENSUS TRACTp -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL /3 jfr!�I] THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SM INFORMATION ONLY. FORM A(6.95) OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRIS STORAGE TANKREGUL ATION /