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�60Vn STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MPONEITEM RK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE 0 2 INTERIM PERMIT � 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE �O I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) DBAOR AM NAME OP ATOR AODR SF NEARESTC STREET PARCEL 0(OPTIONAL) CITY NA STATEZIP SITE PHONE a WITH AREA CODE CA ✓ BOX iNl/l✓✓'�l7 TO INDICATE O CORPORATION 0 INDIVIDUAL =PARTNERSHIP D CAL-AGENCY 0 COUNTYAGENCY' Q STATE-AGENCY' ED FEDERAL-AGENCY' N owner of UST is a public agency,mr plete the following:name of Supervisor of division.section,or office which Operates the UST TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RE/ IF INDIAN SERVATION a OF TANKS AT SITE I E.P.A. I.D.t I WAM4 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bwbivicas 0INDIVIDUAL LOCAL-AGENCY E3 STATE AGENCY Q CORPORATION = PARTNERSHIP OOUNrY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE III, TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boabing"10 = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION =PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ 4 4 -10 ISIq V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓hoRbbAbaY O I SELF-INSUREDGUARANTEE [Ill3 INSURANCE O 4 SURETY BUND (] 5 LETTEROFCREDIT B EXEMPTION = 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.D IL Q 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 8 SIGNED) OWNER'STITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY Al JURISDICTION FACILITYi LOCATION -OPTIONAL CENSUS TRACTS OPJ AUMp jr SUPVISOR-DISTRICT -OPTIONAL 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 FORMA(393) FOROD33AA]