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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION7 PERMANENTLY CLO ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) " MAO. F IL .ME � NAME OF OPERATOR ADDRE S ^ NEAREST CROSS STREET PARCEL 9(OPFIONAL) 1116 J\ A C17Y N STATE ZIP CODE SITE PHONE i WITH AREA CODE 04 CA TO INDICATE p CORPORATION p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNryArA CY• p sTATEAGENCY' p FEDEMLAGENCY' DISTRICTS• 'N owner d UST Is a public agency conplete the fobowkq:narne d Supewisor of dNislon,section,w office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / IF INDIAN 0 OF TANKS AT SITE E.P.A. L D.0(apiard) 0 3 FARM 0 4 PROCESSOR 5 OTHER RESERVATION / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAV NA ST,FIRST) PHONE i WITH AREA CODE YS: NAME(LAST,FIRST) PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE (i it II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindbNe p INDIVIDUAL p LOCAL-AGENCY p STATE AGENCY p CORPORATION p PARTNERSHIP p COUNTY-AGENCY p FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindkale p INDIVIDUAL p LOCAL-AGENCY p STATE-AGENCY p CORPORATION p PARTNERSHIP p COUNTY#GENCY p FEDERAL#GENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-F4-]- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ boa bYtWeaM p 1 SELF-INSURED ED 2 GUARANTEE p 3 INSURANCE p 4 SURETY BOND p 5 LETTEROFCREDT p e EXEMPTION p N 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: 1.0 11.0 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 cP— COUNTY# JURISDICTION# FACILITY# 3 LOCATIONCOOE - TTONAL I CENSUS TRACTS TTIO tv SUPVISOR-DISTJiICTCODE - NAL 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 FORM A(393) FOFOOOMA7