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• x.,o •Ocs .. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a,� `e'o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °:e - COMPLETE THIS FORM FOR EACH FACILITY/SITE m MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS F NEAR ST CROSS STREET I PARCEL#(OPTIONAL) CITY NAME I-- r STATE SITE PHONE#WITH AREA CODE M cu e. Gc<, CA ✓ BOXCORPORATION E:3INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS 11 owner Gf UST is a pubfic agvq,m Tete the following:name ol supemsorof dmon,section oroflice which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE.1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) ❑ ATION 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ �.to ante O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Mxtondiuge [:3 INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY Q CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY i CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4—T47- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to mdnala 0 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND Q 5 LETTER OF CREDIT =J6 EXEMPTION O 7 STATEFUND Q 8 STATE RIND It CHIEF FINANCIAL OFFICER LETTER 09STATE RIND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM O99 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: 1.❑ it.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHVDAYYEAR LOCAL AGENCY USE ONLY !3 COUNTY N JURISDICTION It FACILITYLE # � 5 LOCATION CODE -OPTIONAL CENSUS TRACTN -OPTIONAL SUPVISOR-DI ICT CODE -OP710NAL 1 aa( 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*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUBTORAGE TANK REGULATIONS FORMA(6-95)