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C6\�� STATE OF CA IFL G NIA ' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE F MARK ONLY (L_J1r.�—y_1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 `PERMANENTLY CLOSED SITE ONE ITEM " 2 INTERIM PERMIT E:] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME ��O� — l NAME OF OPERATOR / �� ADDRESS nK(rt 1Aclf// �' �(• NEAREST CROSS STREET PARCEL 1(OPT/ —�O tm� CIN NAME D CX-,70--) STAC`E//�/J,�`ZJIP CODE SITE PHONE p WITH AREA CODE 'Ws 3sr�S_ ✓ BOX ED CORPORATION 014INDNIDUAL O PARTNERSHIP ED LOCAL-AGENCY Q COUNTY-AGENCY' a STATE-AGENCY' (] FEDERAL-AGENCY' TO INDICATE DISTRICTS 'Ilownerol USTRap011cagency.wmpletathelollowing: name of rweMsor of dIvIsion,section of office wild)operates the UST TYPE OF BUSINESS jj�,1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN a OF TANKS AT SITE I E.P.A. I.D.N(optional) I RESERVATON VlGQQ��/ 0 3 FARM Q d PROCESSOR 0 5 OTHER OR TRUST EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:2 (LAST,F,�Bn��dT�i PHONE p WITH AREA CODE�� DAYS: NAME(LAS�IRST) /�� PHONE q WITH AREA CODE NIGHTS: NAMY/`JEjI�If R$1/�_/�� PHZN�kWI(T/1HG/A'RSEA CODE NIGHTS:NIGHTS: NAME(LA-S7T/•F/�I'R/S//T) �[' ONENWI AREA CODE GSGIO /iJ !/ 6 S i II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME /%&) A)� CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ INDIVIDUAL O LOGALAGENCY O STATE-AGENCY O CORPORATION Q P TNERSHIP O COUNTY-AGENCY FEDERAUAGENCY CITY ME STAT ZIP CO E PHONE p WITH AREA CODE o G l C a/ zo III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF W'E / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESB!; L // ✓ pox to ndirata DIVIDUAL = LOCAL-AGENCY INSTATE AGENCY x Al c 9 [__1 CORPORATION O PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY CIN NAME k-7DJ BTATE ' ZIP CODE � pHONE p WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 3`21/2-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bas to indcateL Z�I SELF-INSURED O 2 GUARANTEE = 3 INSURANCE =a SURETYBOND O 5 LETTEROFCREDIT Q 6 EXEMPTION O T STATEFUND Q ED B STATEFUND&CHIEF FINANCIAL OFFICER LET ER = 9 STATEFUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM I= 99 OTHER C VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked, C, CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III.VX 4- -A THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT kR TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYIYEAR bell D 6-0, TM LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY a m LOCATION CODE •OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(695) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS