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STATE OF CALIFORNIA "" c"^ STATE WATER RESOURCES CONTROL BOARD .n UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , ;e COMPLETE THIS FORM FOR EACH FACILITYISITE �.o.�„ MARK ONLY r__j 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY OLD ONE REM O 2 INTERIM PERMIT a a AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) 7CDDE OPAO FACILITYNAME NAME OF RAT RADO E S ,p,� �� NEAREST CROSS STREET PARCEL I(OPTIONAL) v!//V4CITY NAME STATE ZIP CODE SITE PHONE#WITH AR CA .1 Box TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' ED STATE-AGENCY' 0 FEDERALAGENCY' DISTRICTS' 'N owner d UST Is a public agency,complete the following:name of Supervisor of division.section,or office whish operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ' IF INDIAN sOF AN� E E.P.A. I.D.a fopoli RESERVATION Q 3 FARM Q s PROCESSOR 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CT PERSON (SECONDARY)-optional DAYS- NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE (401)715 3 NIGHTS: (LAST,FI I I PHONE#WI AREA N S: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- UST BE COMPLETED NAME G CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Eocbin0kab INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY CITY AMEST h 4 I ZIP DE P NNEE D4 7IT AREA CODE ,Q ) dzal III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STRerrAUDRESS ✓ box snakes INDIVIDUAL E3 LOCAL AGENCY 0 STATE-AGENCY =CORPORATION O PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHONE#WITHAREACODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b iNkme O 1 SELF-INSURED 0 2 GUARANTEE 0 3 P19FRANCE O A SURETY BOND D S LETTER OF CREDIT O e EXEMPTION O 39 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sem 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.O II. III.= THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNEIYS NAME(PRINTED S SIGNED) OWNER'STfTLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# �FACILITY• LOCATION OODE -OPTIONAL CENSUS TRACTS-60TDNAL SUPVISOR-DISTRPT CODE -OPT)i Olwlo THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF We IMFORMkT1OA ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA 13'83) Faa0003A497