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STATEOFCAUFORMA j o STATE WATER RESOURCES CONTROL BOARD a eg n UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A `•. . ., COMPLETE THIS FORM FOR EACH FACILITYTSITE MARK ONLY O t NEW PERMIT ] 3 RENEWAL PERMIT ] 5 CHANGE OF INFORMATION ] 7 PERMANENTLY CLOSE SITE ONE REM Q 2 INTERIM PERMIT ] A AMENDED PERMIT 5 TEMPORARY SITE CLOSURE LJ Q I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACIUTY pAME NAME OF OPERATOR �I ADDRESS /- NEAREST CROSS STREET PARCEL i(OPfONMI Z� 7 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE /,0&7—• cA T INDICA.1 Box �CORPORATION INDIVIDUAL 0 PARTNERSHIP r-1LOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY- FI FEDERALAGENCY' N w er d UST Is a public WencY,oDMI09 the I09owing:name of Supervisor of d"lon,c ion,a oNice which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN i OF TANKS AT SITE E.P.A I.D.#(apl/a al) ] RESERVATION 0 3 FARM a PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST, IRST) P O E i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE G'o4v cD�o t8 -o NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONEi WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION L GD MAILING OR STREET ADDRESS � .1ew blMicate NOIVOUAL OLOCAL-AGENCY (] STATE AGENCY 4:;;r�+ Cr O CORPORATION ARTNERSRP [D COUNTY AGENCY 0 FEDERAL AGENCY ZIP CODE HONE#WITH AREA CODE Go CITY NAME !2�j_ III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OFGAVE R CARE OF ADDRESS INFORMATION MAILING rORf STREET ADDRESS ✓ babedicam f� INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY 7D06C ev� Q CORPORATIOND PARTNERSHIP E-1 COUKYAGENCY O FEDERAL-AGENCY CITY NAME ZIP CODE P��++O__NE i WITH AREA CODE STATE 9�5/ Z 692 -4 3 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ b°r biiMkale O 1 SELF-INSURED O 9 GUARANTEE (] 3 INSURANCE O X SURETY BOND O 5 LETTER OF CREDIT 6 EXEMPTION O 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: 1.Q II.[::] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTE06 SIGNED) OWNER'S TITLE DATE MCNTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTYIV JURISDICTION• FACILITY• &il 1461 LOCATION CODE q-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 1 1 17 3. �v G THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SITE ITFORMATIO ONLY. FORMA OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOfl9033Afl7 (3193)