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CG STATE OF CALIFORNIA `- STATE WATER RESOURCES CONTROL BOARD sy UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A Coo COMPLETE THIS FORM FOR EACH ITYI8ITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Drs CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE �/ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 1 ADDRESS NEAREST CROSS STREET PARCEL#(OFrxDNAD CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Sa��AY ca 9sazz� BOX CORPORATION INDIVIDUAL PARTNERSHIP E:l LOCAL-AGENCY Q COUNrYAGENCY STATE AGENCY FEDERAL-AGENCY DISTNI CTS TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN ISOF TANKS AT SITE E.P.A. L D.0(Oprknal) RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PWnNC A II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box waM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box WmaU Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY _ Q CORPORATION Q PARTNERSHIP El COUNTY-AGENCY Q FEDERAL#GENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE .BOARD OF EQUALIZATION UST STORAGE FEE ACCO T NUMBER•Call(916)323-9555 if questions arise. TY(TK) 4 HO 4 - ROLEUWLIST FINANCIRESPONSIBILI •(MU TBE COMPLETED)—IDENTIFY THEMETHO IS) USED ✓ bYNinM 0 2 GUARANTEE Q 3 INS/URANCE Q 4 SURETY BOND Q 5 LETrEROFCREOT Q S EXEMPTION Q %.OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS L I notification and billing will be sent to the tank owner unl box I or II is checked. CHECK ONE BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGTIFICA=NS AND WG: L ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANT$TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# F 8 LOCATION CGDE -OPTIONAL CENSUS TRACT# -OP7:ONAL SUPVISOR-DISTRICT CODE -OPTIONAL 0 a 340 1 3a 3 THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FQQMA(S91) -^ \ _- -. — f0i1W73A5h \ W\I I� � L.�\ ��r�rt )•�1.v J