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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F__j I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Eff 7 PERMANENTLY CLOSED BITE ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE 5Z I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAO AGILITY NAME NAMED TOR ADDgF33)9 NEARS C SSSS A PARCEIe(OPrONAy CITYNAM STATEZIP CppE SITE PHONE a WITH AREA CODE CA (}!� TOINDICATE O CORPORATION 0 INDIVIDUAL PARTNERSHIP IACALAGENCY O COUMY#GENCY• ED STATE-AGEN:Y' FEDEML-AGENCY' DISTRICTS' 9 owner d UST Is a public agency,complete,the fo9oMng:narne d Supervisor of eNbion,section,w office which operalee the UST TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION /IFIINDIAN 18 OF TANKS AT SITE E.P.A. I.D.9 ibbol mall 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bMillyde%e = INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNE4 INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bei biMkate E:1 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY []CORPORATION O PARTNERSHIP COUNTY-AGENCY E::] FEDERAL AGENCY CITY NAME STATE 21P CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓5m NYItlNaN D 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND 5 IE17ERGFCREW 8 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 It is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[�] it.Q Ill.Q THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&S IGNED) OWNER'STITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY C�OUN'T�Vu JURISDICTION• FACILITY# . / � LOCATNDNCODE - DONAL CENSUST T - SUPVISOR-D� TCCODE • Z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS tHIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FGRom3ART FORM A(193)