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o„-«g STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD r , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ;;�'7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORrTY NAME NAME OF c4 L ?3 ADDRESS NEARESTC OSS TREET PARCEL#(OPTIONAL) CITY NAME STATEf ZIP CODE SITE PHONE#WITH AREA CODE `FD DC7 CA ✓ BOX CORPORATION NDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY- STATE-AGENCY' FEDERAL-AGENCY' TO INDICATE DISTRICTS "It ower of UST is a public agency,complete the following:name of supervisor o1 division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P,A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR C—] 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS,N AME(LAS�FIRST) PHONE# ITR AREA CODE DAYS: NAS,(LAST,FJRS PHONE#WITH ARE OpOE NIGHTS: NAME(LAST,FIRST) PH NE#WITH CODE NIGHTS:: NAME`(LA—ST,FIRST) PHONE#WITH AREA CODE 1 �lr1j Il. 'PROPERTY OWNER INFORMATION-(MUST BE C0l1I8PLFTF:m NAME CARE OF ADDRESS INFORMATION IF;CtA fl� I✓AILINf.,OR STR ET A„QDRESS ✓ t,:V:i f.c;'�^ Iti7:ViDUbL {IL fr3RS ►W/`/ 0 0 LOCAL-AGENCY [] STATE•AGENCY CORPORATION O PARTNERSHIP {] COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME qF OWNER CARE OF ADDRESS INFORMATION L/ / MAILING OR 81fiEET ADDRESS ✓ box to indicate ;�-ODIVIDJAL Q LOCAL,AGENCY Q STATE•AGENCY 32— CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL•AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE e"6, 6,A- ?_�b2a 1V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ � 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate Epli—SELF-INSURED 0 2 GUARANTEE ELI 3 INSURANCE © 4 SURETY 60ND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND = 8 STATE FUND&CHIEF RNANCIAL OFFICER LETTER = 9 STATE FIEND&CERTIFICATE OF DEPOSIT I= 10 LOCAL GOVT.MECHANISM = 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 13OX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ III.= THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRI TED&SIGNATURE) -- TANK OWNER'S TITLE DATE MONTWDAWYEAR a L� min? LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95}