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�60Ve STATEOFCAUFORMA _�� - STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION7 PERMAN y OLD ONE REM 2 INTERIM PERMIT E] 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITY NAME ` NAMEOFOPERATOR AODRESS I NEAREST CROSS STREET PARCELa(OPT C1 STATE Z CODE SITE PHONE s WITH AREA CODE ✓ CA qg Box AYA TO INDICATE 11i6PORATION ED INDIVIDUAL PARTNERSHIP Q LOCALAGENCY O COUNTY-AGENCY' STATE.AGENCY' O FEDERAL,NGEICY• x pVner d UST Is a public agency,oomplge the folbwirp:nartw Of Supervisor Of ONYto eq:iio DISTRICTS' w oNioe which operan"the UST TYPE OF BUSINESS [L?/GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN s OF TANKS Al SITE E.P.A I.D.a(gdlmml Q 3 FARM 4 PROCESSOR 0 5 OR OTHER flTRUST TRUST NDS 0 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional L.DIIIVS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA;COEII�LJl3 U- vNI TS: NAME(LAST.FIRST) PHONE a WITH AREA WOE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA 1 5)o- tiara II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION �AeurvN MA�••ILYYIN11G��OR STREET ADDRESS ✓aorbbdkab = INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY t!•TI0 C.,mm OR-eMPORATN)N 0 PARTNERSHIP O CDUNTYAGENCY O FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION e J R,0 MAILING OR STREET ADDRESS ✓boa bbOkaN = INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY a341 YYA L�'C5iPORATION = PARTNERSHIP [:]COUNTY-AGENCY O FEDEML-AGENCY CITY NAME STATEPHONE a WITH AREA CODE ZIP CODE cq 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 METHOD(S) USED bpabklicab O I SELF INSURED p 2 GUARANTEE INSURANCE O 4 SURETYBOND 5 LETTEROFCREDIT =a EXEMPTION =99 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USEDFOR LEGAL NOTIFICATK)NS AND BILLING: 1.D II.�11.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NTED a SIGNED) _ OWNERSTITLE DATE MCNTHIDAYNEAR S- LOCAL AGENCY USE ONL r y7 COUNTY tJURI�a FACILITYi ` 6 LV��7birl LOCATION CODE -OPTIONAL CENSUSTRA OPTIONAL a - SUPVISOR-DIS R TCODE -OPTIONAL 0 03 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE PERMITAPPLICATION• FOR B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWNS FORM A(3A)3) n FOR(X*ART .. ///6fCAf l3[