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STATE OFCAUPoRMA STATE WATER RESOURCES OL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A y' COMPLETE THIS FORM FOR EACH FACILITY/SITE •r^l/0^M,� D MARK ONLY �1 NEW PERMIT O 3 RENEWAL PERMIT ONE ITEM O 2 INTERIM PERMIT O O a CHANCE OF SITEINFOCLOSURE 7 PERMANENT CLOSED SITE 4 AMENDED PERMIT � g TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS- DSA OR FACILITY NAME (MUST BE COMPLETED) NAME OF OPERATOR ADDRESS IM—+ NEAREST CROSS STREET PARCEL 0(Opno"L) CITY NA STATE ZIP CODE ✓BOX CA SIZE PHONE a WITH AREA CODE TO INDICATE 1]CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP (] LOCAL-AGENCY 0 COUNTY U ENCY, 'x owner d UST Is a blit a DISTRICTS' 0STATE-AGENCY' (] FEDEMLAGENCY W agenry,Wnplete the lollawbg:name of Supervypr of dNYbn,section,or OMW which DIDWata the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS 1IITE E.P.A. 1.Me(aptlanap 3 FARM Q A PROCESSOR 0 5 OTHER OOR RESERVATION EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•aptional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME MST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bM bYIOIC#s 0 INDIVIDUAL 0 LDCAL-AGENCY 0 STATE-AGENCY O CORPORATION 0 PARTNERSHIP ED COUNTYAGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION- MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓hw bsi9eW O INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY ED CORPORATION 0 PARTNERSHIP D COUKrYAGENCY O FEDERALAGENCY 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 ✓ bol bin1K t. O I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O A SURETY BOND 5 LETrEROFCREOT D e EXEMFnON O ss 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 11.0 IN.O 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# FT-1 LOCATION CODE -OPTIONAL CENSUS TRI -OPTIONAL SUPVISOR-DISTRICT CODE -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 FORM A(393) VVI &1v4k6__' VL/ ��