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!46 � STATE OF CALIFORNIA k ti STATE WATER RESOURCES CONTROL BOARD `mom' :e / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , COMPLETE THIS FORM FOR EACH FACILrTY/SITE � �4nU�M" MARK ONLY F-1 t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO SITE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE .S I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAORFACI NAME / NAMEOFOPERATOR Y, 's �laC�ron ADDRESS Q� NEAREST CROSS STREET PARCEL a(OPTIONAL) O f• oSC/'Vl/ 'C CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE G� ry CA 05 336 TOINGOX f�CORPORATION 0 INDIVIDUAL �PARTNERSHIP � LOCAL-AGENCY �COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' DISTRICTS' If owner el UST Is a public agency,m Isle the tollowing:narre of Supervisor of division.section,or office which operates the UST TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN i OF TANKS AT SITE RESERVATION I E.P.A. 1.D.i(opNmaq Q 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME q /� CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS , \ ✓ INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY 114037- S • f1 CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITU NAME 1 STA ZIP CODE PHONE a WITH AREA CODE a III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box Is Indicate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY E:)CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAUAGENGV CITY NAME STATE ZIP CODE PHONE i WITH AREA GAME IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box bYtlbale 0 t SELF-INSURED =2 GUARANTEE 3 INSURANCE 4 SURETY BOND D 5 LET TER OF CREDIT O 8 EXEMPTION 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: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PAINTED&SIGNED) OWNER'STITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If FACILITY# ® I z 9 LOCATION CODE -OPTIONAL CENSUS TRACTS OPTIONAL SUPVISOR-DISTRICT CARE -OPTpIVAL / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SrTE INFORMATION ONLY. OWNER MUST FILE THIS FOR;F THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND�STORAGE TANK REGULATIONS FORM A(3'93) .. FOR7NIAA]