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'`e s cos ' STATE OF CALIFORNIA =� ' STATE WATER RESOURCES CONTROL BOARD e UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A :, , .in COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION It ADDRESS-(MUST BE COMPLETED) AT (a- DBA OR F M NAME ♦ NAME OF OPERATOR ADORE NEAREST CROSS STREET PARCEL I(OPTIONAL) CITY E G ST TE ZIP ODJ D SITE PHONEX WITH JCODEGA ✓BOX (]CORPORATION Q INDMWAL I�PARTNERSHIP Q LOCAL-AGENCY 0 COOMTY-AGENCY' I�STATE-AGENCY' 0TO INDICATE DISTRICTS 8o 01USTeap10ioagmry.ma ,l NefolbwFg� Gf WaneorofBAskn,secbmmolkoAirhopa asMeUSTTYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ❑ RESEIRVAT1ONX OF TANKS AT SITE E.P.A. I.D.X(optio ❑ 3 FARM Q a PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE It. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME — CARE OF ADDRESS I C=:)(?-A'TIODN /N MNLING OR EET � KESS ✓ �ba l//`=1 IDIVIDUAL -V Q LOCAL-AGENCY STATE—AGENCY Q CORPORATION O PARTNERSHIP 0 CoUw Y-AGENCY ED FEDERAL-AGENCY CITY ^\Ja STAT ZIP CODE N W TM AREA COD= ^ OV Ill. TAOWNER INFORMATION-(MUST BE COMPLETED) G NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bosfo nEimte Q INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY =CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HO M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indmW D I SELF-INSURED 0 2 GUARANTEE =3 INSURANCE =A SURETY BOND =5 LErrEROFCREDTT 0 6 EXEMFnON O 7 BTATE FUND O 85TATE FUND B CHIEF FINANCIAL OFFICER LETTER O B STATERBDBCERTLnCATEOFOEPOSIT 010 LOCAL GOVT.MECHANISM 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: I.❑ II.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE ANO CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY p COUNTY X JURISDICTION X BSL S 0 LOCATION CODE -OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DIS ICT C AL 0 N C 8 5 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. p OWNER MUST FILE THIS FOW1""TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI"1n STORAGE TAN t7CIlOR '�'3(('1 FORM A(6-U5)