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STAT60FCALIFORMA STATE WATER RESOURCES CONTROL BOARD W�g :B A- _ UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A A '•. COMPLETE THIS FORM FOR EACH FACILITYISITE �""°""�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [—] e TEMPORARY SITE CLOSURE 7 I. FACILITY/SITE INFORMATION&ADDRESS-(MU E COMPLETED) OBAORFACI TYNAM pp NAME OF OPERATOR 'a CLu r- ADDRESS NEAREST CROSS STREET PARCELa(OPTKINAL) Z- �. 1L ; a� CITY NAME STATE ZIP CODE SITE PHONE Ill WITH AREA CODE _OCCA 95 Z10 TV Box Ac TE COALRPORATION O INDIVIDUAL ED PARTNERSwP O LOCDISTr.AGFNCY 0 COUNTY-AGENCY• O STATE-AGENCY' O FEDERAL-AGENCY• •5 owner of UST Is a public agency.conplele the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ gESEIgyATION i TAN—K7S AT SITE E.P.A I.D.i(aplMrS ❑ 3 FARM ❑ 4 PROCESSOR - of OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME a, CARE OF ADDRESS INFORMATION f� MAILING OR STBEETADDRESS ✓5W bin kib O INDIVIDUAL LOCAL AGENCY OSTATE-AGENCY q LX D CORPORATION = PARTNERSHIP0 CDUNrY-AGENCY ED FEDERALAGENCY CITY NAME STATE ZIP CODE 7 6 z PZo a�WITH A7 A7 23 7S III. TANK OWNER INFORMATION- MUST BE COMPLETED) [7y NAME OF OWNER CARE OF ADDRESS INFORMATION scir MAILING OR STREET ADDRESS ✓box biW!OM INDIVIDUAL E-3 LOCAL-AGENCY 0 STATE-AGENCY []CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME IP 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- - J V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED ✓hm bloaexe O l SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREGT 0 6 MIAPTION O 29 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ched(ed. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It. Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED IS SIGNED) OWNERS TIRE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY 1 [01--- - � LOOATXON CODE -OP77ONAL CENSUS TRACT# -OPTIONAL SUPVISOR•D�OT CODE -OPTIONAL ® ZI / A 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 REWTT\`QY FORM ATIM) ^ jj �, u C