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eyoURGe STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD s /� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A /_J •c��Fon N� COMPLETE THIS FORM F ACH FACT Y/SITE MARK ONLY (L_ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CH GE OF INFORMATION 7 PERMANENTLY CLOS 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 7— C9 6101rt ADDRESS NEAREST CROSS STREIfT PARCEL (OPTIONAL) � CITY NAME STATE ZIP CODE TE PHONE N WITH AREA CODE IN�a�n�cc CA 5 36 3- y I ✓ BCA ORPORATION l�INDIVIDUAL (� PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY TO INDICATE � FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESERVATION NOF TANKS AT ITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS CAL W 0ti4 55'0— EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) p PHONE#WITHH7AREA CODES DAYS: NAME(LAST,FIRST) PHONE:*WITH AREA rom: NIGHTS: NAME(LAST.FIRST) 1 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 14-i v r9C2 -a77--b3L/`t PHONE#WITH ARE CODE . PROPERTY OWNER INFORMATION- MUST BE COMPLETED 444 ECARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY Cj STATE-AGENCY QD CORPORATION Q PARTNERSHIP [] COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME C� STATE ZIP CODE PHONE#WITH AREA CODE r s 1 a Q/0070-L — &03 5,- Ill. III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 11.3 MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL F-1 LOCAL-AGENCY (]STATE-AGENCY 0 CORPORATION Q PARTNERSHIP L__] COUNTY-AGENCY Q FEDERAL-AGENCY 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) HQ 14 14 j-;I QI pjo]S Op 6J V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED E]2 GUARANTEE L J 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT I=6 EXEMPTION [_1 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.El II. III. THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACI ITY# 14k C05 7 3 .5 _1--E] =I f 4 -sem_ s 1 LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL © I -13 ZG 3-7Dq--Q3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(tz 91) FILE THIS FORM WITH THr LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-R6