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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S1TE ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OPA Oq FACIU}TY NAME AVEOF OPE OR V I N ADDRESS NEAREST CROSS STREET PARCELf IOPTONAL) CITY NUUMIT ST TEZIP SITE PHONE i WITH AREA CODE CA Box D CORPORATION INDIVIDUAL O PARTNERSHIP =COUNTY-AGENCY' STATE-AGENCY' O FEDENAL-AGENCY' •N owner d UST is a Public agerwy,corrpleb the following:cane of S DISTRICTS' p Supervisor W tlNlabn,section,W otlim whbh operates the UST TYPE OF BUSINESS O 1 (SAS STATION 2 DISTRIBUTOR Q '/ IF INDIAN s OF TANKS ATSITE E.P.A I.D.a(npriia u) RESERVATION 3 FARM 4 PROCESSOR S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAV ' AVE(I-AST,FIRST) PHONE a WIT AREA CODE DAYS:NAME MST,FIRST) PHONE a WITH AREA CODE 4-71 NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE IL % q I1. PROPERTY OWNER INFORM ION• MUST BE COMPLETED NAME CARE OF ADDRESS I ORMATION MAILING OR STREET ADDRESS ✓ Ewbebicate VIDUAL ED.LOCAL-AGENCY OSTATE-AGENCY (]CORPORATION 11 P TNERSHIP D COUNTY AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION-(MUST COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa bbalkm INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY _ I�CORPORATION M PARTNERSHIP CY AGENCY E-1FEDERAL-AGENCYCITY NAME WM STATE ZIP CODE NE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE AC OUNT NUMBER-Call(916)322-9669 it questions aril . TY(TK) HQ F4-14--]- V. 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boG biMicate ED I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE I�5 LETTEROFCREDFT 4 SURETY BOND O 8 EXEMPTION Q m 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 IL III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY 3 COUNTY M JURISDICTION a FACILITY s m LOCATION CODE -OPTIONAL CENSUS TRACT e -OP770ML SUPVISOR-DISTRICT CODE -W 0 0490 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IN96RMAbOA ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) Fpi0p3]A447 43_ i�- 9�