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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 3 •mom �e COMPLETE THIS FORM FOR EA i0i FACILITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT SED " ONE ITEM 5 CHANGE OF INFORMATION O7 p ANENTLV CLOSED 517E ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED) _ DSA OR FACILITY NAME Q AA-,Nu aC J-u NAMEOFOPERATOR ADDRESS �7 7 N ,SO NEARESTCROSSSTREET PARCEL#(OPTIONAL) CITU NAME iN-I STATE ZIP CODE C�PN CA �s SITE PHONE#WITH AREA CODEv Box _' — TOINOICATE [:]CORPORATION O INDIVIDUAL (]PARTNERSHIP LOCAL-AGENCY Q COUNrV-AGENCY OLSTRICTS �STATE-AGENCY 0 FEDEMLAGENCY TYPEOF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.F A. I.D.x(opfi.W) ❑ 3 FARM O 4 PRODESSOR 5 OTHER 0 RESERVATION D OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS; NAME(LAST,FIRSD PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAS,,,,,,,) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS // ✓ boabbidicalm INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY - 0. �O v O CORPORATION (] PARTNERSHIP E-1 COUKrYAGENCY Q FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 1 �� ,� 95z3� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION aC MAILING ORSTR TADDRESS ✓ boa bindicaN 0 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY 0 CORPORATION (] PARTNERSHIP (] COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 kJ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa bintlbad I SELF INSURED 2 GUARAMEE O 9 INSURANCE =4 SURETY BOND 5 LETTEROFCREDT S 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' Checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �� 23 .E 32s" 2 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLFORY.Ad FORM A(5-91)