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i. • � °rsoon e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL 0 JOPTN)NAU lS�,i-. CITY NAME STATE ZIP CODE SITE PHONE p WITH AREA CODE S/oC_ wiz. - CA TO INDICATE =IC Q INDIVIDUAL (] PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN p OF TANKS AT SITE E.P.A. I.D.p(optimal) - RESERVATION O 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: AME(LAST,FIRST) 7 tl PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) �{' S✓✓, TLS C. Ly --PHONE 9 WITH AREA Coop NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ': a � CARE OF ADDRESS INFORMATION MAILING 09 STREET ADDRESS ✓ box bintlbata INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY 3 3 b O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME `C STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION/-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• ✓ w bIMi to INDIVIDUAL O LOCAL-AGENCY (] STATE AGENCY CORPORATION PARTNERSHIP O COUNTY-AGENCY 0FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE IV.BOARD 0 EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO LZ]-�� Z V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED ✓ boa bindicale I SELF INSURED 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND = 5 LETTEROFCREDIT 6 EXEMPTION El 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is the d. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.EVIII. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTIVDAY/YEAR LOCAL AGENCY USE ONLY COUNTY p JURISDICTION N FACILITY n gay SO 13�9,I SCI �� LOCATION CODE -OPTIONAL CENSUSTRACTA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL y /I/ 14 3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFSITE INFORMATION ONLY. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • • FOR0033A-R6