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n�sooa e STATE OFCAUFORNIA t ` , STATE WATER RESOURCES CONTROL BOARD g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ro; . C�<InO1�M� CO LETE THIS FORM FOR EACH FACILrrY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O/ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME 6-& ,/ 7-0/00/ NAME OF OPEflATOR ADD lj/� ` T�`j a�Jl/�/.. NE STCROS TREET PAR GEL x(OPnONAL) CI N STATE COQF�.D� SITE PHONE M WITH AREA CODE CA �L/- I/ BOX TO INDICATE CORPORATION INDIVIDUAL D PARTNERSHIP LOCAL AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ INDIAN #OF TANK T SITE E.P.A. I.D.#Nophmal) ❑ 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA cOng NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH APRA Mn- 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME /t CARE OF ADDRESS INFORMATION MAI GORSTREETnADDRES (fet ✓box to[mints D INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY e Vx g D CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY FEDERAL AGENCY TY N ME• ST ZIP CODE '�_ H NE#WIT AREA CODE Z'3 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b(Mints Q INDIVIDUAL D LOCAL-AGENCY =STATE-AGENCY 0 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEOERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO 14141-[I V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eox biMbab (_J 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE _ 1 A SURETY BOND I—.I 5 LETTEROFCREDIT 6 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' checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.n it. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COHHECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION COCIE��IOPTIONAL CENSUSTI'f_T OPTIO�(4ASUPVISOI3>.�IBTRI TCODE OPTIONAL THIS FORM//VV//MUST BE ACCOMPANIED BY AT LEAST(1)OR/MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, FORM AI1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS Fpn 2Q* '�2(0� A