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♦ a STATE OF CAUFORTSASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT FSr6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM I] 2 INTERIM PERMIT Q A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE v a„ 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DIMOP,FACILrTY NAME NAME OF OPERATOR ADDRE S NEAREST CROSS STREET PARCEL#(OPTIONAL) CI1Y NAME STATE ZIP CODE SITE PHONE I WITH AREA CODE G CA TO BoxCORPORATIONCORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL#OENCY' DISTRICTS' 'If memr of UST M a public agency,conplele the folowing:name of SUPervNor Of division,section,or office which opawlw the UST TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(op6orW) RESERVATION 3 FARM Q A PROCESSOR 5 OTHER OR TRUST LANDS ' EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimist DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME MST,FIRST) PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED Ph0GZA G p NAM CARE OF RESS INFO TION W MAILING ORSTREET ADDRSS ✓ box blMleate O INDIVIDUAL OLOCAL-AGENCY STATE AGENCY O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY CITY AM rA nkstO s?/ ZIP CODE P�E e A COOS / III. TANK OWNER INFORMATION-(MUST BE COMPLETED) Ct 5.3,9 A �I NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓be[b Nita INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY CORPORATION D PARTNERSHIP a COUNTYAGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE N.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 R questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓�bbmcW El I SEURNSURED L_j 2 GUARANTEE 3 INSURANCE N A f U IO 4 SURETY BOND =5 LETTER OF CREDIT O 6 EXEMPTION (] 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sem 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.O II. 111.0 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED S SIGNED) OWNERS TITLE DATE MONTHIDAY/YEAR LOCAL AGENCY USE ONLY Q COUNTY# JURISDICTION# FACILITY i FTFI LOCATION CODE-OPTIONAL CENSUS TRACT#-Q°TIONAL 9UPVISOR-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 wimmTION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK RE�GULLAT"S FORM A(393) lqq/ � ,_t'� " ;kL - 1 '-f `.-r#2 WR0m3AAT