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• o ^=4 STATE OF CALIFORNIA �O*. STATE WATER RESOURCES CONTROL BOARD i,,,�, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A > - , COMPLETE THIS FORM FOR EACH FACILITY/SITE m MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR G v e >`vwl ADDRESS NEAREST CROSS STREET PARCEL a IOPPONAL) l 30 A /tl4 S7' Ov Z> -LID CITY NAME STATE ZIP CODE ,SITE PHONE#WITH AREA CO rF CA 9 _ ° s ✓BOX (j CORPORATION [_1 INDIVIDUAL I::] PARTNERSHIP [:1 LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' D FEDERAL-AGENCY' TO INDICATE DISTRICTS 'M ownerof UST6 a public agency,mmplete the following namedswer roldNi W.sectionoro#icewhichoperatesthe UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ REV IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST[FIRST) NONE WITH AREACODE DA S: NAME(LOST,FlRST) PHON WITH AREA CODE zC9 Z3 _ 06 67 ZoG =12v 3 - NIGHTSiAME(LAST,FIRST) IZPCIOON WI AREA CODE NIGHTj=AME(LAST,FFIRST) �PPHO WI AREA CODE l/ J/ S S ,1',T` II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFT_O) NAME _ CARE OF ADDRESS INFORMATION MAILING OR STREET AD ESS INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY O C AQfl CeAQ CORPORATION I� PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME? STATE ZIP CODE ONE# TH AREA CODE �voo ��7 9/ 6'/- o/ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILI GpOR STREETA FEES ✓ boxtondimte OINDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY ZO T 3� O CORPORATION O PARTNERSHIP O COUNTY-AGENCY Q FEDERAL- GENCY CITYY NAME�I STATE ZIP CODE PHONE ITH AREA CODE 1C,1>4 IV. BOARD OF EQUALIZAT�IONI 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 ✓box loiMcele 1 SELF-INSURED 0 2 GUARANTEE =S INSURANCE O 4 SURETY BOND L—I 5 LETTEROFCREDIT O 6 EXEMPTION O 7 STATE FUND � 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER O B STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 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: I. 11.❑ III.Q 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 OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# z,FACILITY# �{ LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 UNDERGROSTORAGE TANK REGULATIONS FORM A(6.95)