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• F taus• � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY D t NEW PERMIT IEZ3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR JA A ADDRESS o,_ NEARESTCROSS STREET PARCEL#(OPTIONAL) 65>1 G- � CITY NAME STATE ZIP CODE SITE PH NE#WITH AREA CODE OCA Z —q7 J INDICATE CORPORATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' DISTRICTS' If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF 4TANSAT SITE E.P.A. 1.D.#(optional) RESERVATION FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDSEMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY COACT PERSON (SECONDARY)-optional DAYS: NAME(L ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE All prygf_ — o NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION ::C7n � M i",1, Si F MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY &1 CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE 2 G J� PHONE#WITH AREACODE � 271,r 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) / 3 LPA NAME OF CtVNER CARE OF ADDRESS INFORMATION v -� MAILING OR STET ADD ESS �p�^ ✓ box b indicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY 460 0'. �L�^ / r G� CORPORATION = TNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAE STATE ZIP CODE J,PHONEJ WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓ box to indicate (] 1 SELF-INSURED =2 GUARANTEE [__1 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT E:J 6 EXEMPTION Q 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.E] ll. III.O THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL 9 0 23, 4S6 � 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3/93) FOROMM-R7 � ��or�/