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C STATEOFCAUFOIIMA STATE WATER RESOURCES CONTROL BOARD 3 ° UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , o COMPLETE THIS FORM FOR EACH FACILITYISITE `•�.e.+'' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE _ ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) DBAO FACILITY NAME ,LIQ NAME OF OPERATOR AODR SS 6 1 NEAREST ROSSSTREET PARCEL#(OPIONAU ahtqcc, CITU NAME I STATE ZIP�4PDE SITE PHON #WITH AREA CODE T�CTY�yv CAoG 4 TI/ Box xTE CORPORATION O INDIVIDUAL O PARTNERSHIP LOCALAGENCY 0 COUNTY-AWNCV' O STATE-AGENCY' 0 FEOEMLAGENCV' DISTRICTS' 'H cone,d UST Is a pubbc agency,cerrphse the following:name d Supervisor of division,section.W office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION [:] 2 DISTRIBUTOR R SERVATION #OF TANKS AT SITE E.P.0. I.D.#(oPlbuS 0 3 FARM ❑ 4 PROCESSOR x 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS NAME(UST,FIRS PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ODE6 � N S:NAME(LAST.FIRST) PHON WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMEr CARE OF ADDRESS INFORMATION MAILING OR STREET ADORES ✓Out ilmlic N 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY (]CORPORATION O PARTNERSHIP 0 CWNTYAGENCY [] FEDERALAGENCY CITY M STATE ZIP DE PHONE TH AREA COPE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blMkas 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION D PARTNERSHIP O COUNTYAGENCY D 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 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓Wbintlkme O t SELF-INSURED 0 2 GUARANTEE 0 3INSURANCE 0 4 SURETY BOND D 5 LETTER OF CREDIT O e EXEMPTION O 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: L❑ 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(PRINTED&SIGNED) OWNER'S TITLE DATE MON/TKKOAY/YEAR LOCAL AGENCY USE ONLY ) / �— COUNTY If JURISDK)TKNd a FACILITY a LOCATION CODE -OPTIONAL CENSUSM-OPTSupvISOR-DISTR2r,'7 TFYS FORM14 IST 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(S93) FOROmMAT cAI(olgL� L-�— 41— �4"!�