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STATEOFCALIFORMA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONE REM 2 INTERIM PERMIT � 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE Z I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NFjBBEST CROSS STREET PARCEL#(OPTIONAL) �— - CIN NAME STATE ZIP CODE ITE PHONE•W ITH AREA CODE Gvp CA ✓ BOX TO INDICATE O CORPORATION (] INDIVIDUALPARTNERSHIPLOCALAGENCY PARTNERSHIP DISTRICTS' CAUMYdGENCY' OSTATE-AGENCYFEOEf1AL#GENCY' If owner d UST is a public agency,comis a the following:name of Supervisor of dHbbn,section,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATION _j #OF TANKS AT SITE E.P.A. I.D.#(goGana/J 0 3 FARM = 4 PROCESSOR 4?q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optimal DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION *vL OF 'ieES MAILING OR STREET ADDRESS ✓ boxbinENale =1 INDIVIDUAL O LOCAL 0 STATE AGENCY 7 (� O O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY ] FEDERAL AGENCY CITY NAM STATE CODE PHONE#WIT AREA CODE )* D ZIP 37o/-/c, v ) III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OFO NER !/` / CARE OF ADDRESS INFORMATION VLdF r MAILING OR STREET ADDRESS ✓ bot b lnskle E--1aINDIVIDUAL Q LOCALAGENCY O STATEAGENCY ! � /iqC ^Sr CORPORATION O PARTNERSHIP COUNTY AGENCY E-1 I'MEML-AGENCY CITY NAME STAFF, ZIP CODE PHONE A WITH AREA CODE FTP% A 737a/ /D/L) 2°a) 7- 71- IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bintlNMe [–I l SELF INSURED O 2 GUARANTEE O 3 INSURANCE 0 4 SUflLT'BONG 1:J5 LETTEROFCREDIT 5 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.O II. If THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C&RECT OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIOAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTXNM O G3. ?jto THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFoRMA ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FORNIVIA117