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•0 ptSpUnCS CO STATE OF CALIFORNIA �P STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a� COMPLETE THIS FORM FOR EACH FACILITYISITE • ��1,•pp N.� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY TE ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE` ' I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME /Aaq G-iL'04�j Z NAME OF OPERATOR P 1.7 ADDRESS NEAREST CROSS STREET PARCEL# (OPTIONAL) 2 Z,y- '49�iG> =D 6;F -- STATE CITY NAME �Q STATE CA ZIP CODE ITE PHONE # WITH AREA CODE ✓ BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY Q COUNTY-AGENCYSTATE-AGENCY' D FEDERAL -AGENCY' TO INDICATE 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 # OFTANKS AT SITE E. P. A. I. D. # (optional) RESERVATION I 71 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHON # WITH AREA CODE �gc ✓ a 3M —/960 DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 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 MAILING OR STREET ADDRESS we box to indicate Q INDIVIDUAL Q LOCAL -AGENCY STATE -AGENCY %+Q4'6:0p'j % O CORPORATION Q PARTNERSHIP D COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE G©a ZIP CODE p/� 61 Z 111. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION G mei S - MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY `L Z,o —rw 61��Iiq = CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAMESTATE Z --O � / ZIP CODE p/� PHONE # 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 = 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND & CERTIFICATE OF DEPOSIT = 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 1 or 11 is checked. ICHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ II. ❑ 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 (PRINTED & SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # ❑ FTTI I 1 1.1 A I o1z' LOCATION CODE 'OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL �Z 2� �0 3Lv THIS FORM MUST BE ACCOMPANIED BY AT EAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLES THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (6-95) OWNER MUST FILE THIS FOVITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGFW STORAGE TANK REGULATIONS