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" f- - 0 w � dQ�.cra . s STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o' COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ;t NEW PERMIT 0 3 RENEWAL PERMIT 1:J 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM t U 2 INTERIM PERMIT Q 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NNE �� , NAME OF OPERATOR ADDRESS � � � �/�I c��'. NEAREST CROSS STET � PARCEL a(OPTIONAL) CITY NAME .r— - STATE ZIP CODE '� _ SITE PHONE#WITH AREA CODE: CA S 2- 7 5d ✓Box CORPORATION I Q INDNI15UAL Q PARTNERSHIP []LOCAL-AGENCY Q COUNTY-AGENCY' © STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS tl Omar of UST 4 a public agency,complete,the following:name al supervisor of divislon,sedan or office whids operates the UST TYPE OF BUSINESS O 1 GAS STATION �_3 2 DISTRIBUTOR Q ✓IF INDIAN I#.OF TANKS AT SITE E.P.A. I.D.#(opi anal) 3 FARM EO`4 PROCESSOR Q 5 OTHER ORRTRUST VLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 4s' -7 - NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE CO"PLFTI'D) NAMECARE OF ADDRESS INFORMATION IC jF C. S 60 MAILING OR STREET A5RESS _✓ bco IU 6:23,a © NIXVIOUAL Q LOCAL-AGENCY {]STATE-AGENCY 0 . ax ,CORPORATION C] PARTNERSHIP Q COUNTY-AGENCY [] FEDERAL-AGENCY CITY NAME - STPy� - ZSP C DE PHONE#WITH AREA CODE III, TANK OWNER INFORMATI. N-(MUST BE COMPLETED) NAME OF OWNER - CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate - © INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION =PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 6 I IV.BOARD OF EQUALIZATIO UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ gv — V.'PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)--IDENTIFY THE METHOD(S) USED ✓box la Indicate Q 1 SELF-INSURED []2 GUARANTEE Q 3 INSURANCE [�:]4 SUAMBOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATEFUND ©6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 4 STATE FUND&CERTIFICATE OF DEPOSIT Q 19 LOCAL GOVT.MECHANISM (= 84 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. IE.Q III.O THIS FORM HAS.BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG,&,1S TRUE AND CORRECT TANK OWNER'S NAME PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTFVDA'NEAR I� Q re Qr�s 4 4. LOCA A CY USE ONLY COUNTY# JURISDICTION# FACILITY# 1 m LOCATION CODE: -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM S,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) �A