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i' a STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY IVI NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORF N E NAME OF OPERATOR ADDRESS 00 W. �1 NEAREST CROSS STREET PARCEL#(OPrIONAU CITY NAME `✓-S7T_ STATE ZIP ^ SITE PHONE t WITH AREA CODE CABOX JL TO INDICATE [_1 CORPORATION E] INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY D COUNTY-AGENCY 0 STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTORO ✓ IF INDIAN a OFT T SITE E.P.A. I.D.It(optimal) RESERVATION 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) It. PROPERTY OWNER INFORMATION- UST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blMkriA INDIVIDUAL O LOCAL AGENCY STATE-AGENCY CORPORATION O PARTNERS IP O COUNTYAGENCY Q FEDERAL-AGENCY 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 ADORES$ ✓ babir&M M INDIVIDUAL 0 LOCAL-AGENCY 0 STATEAGENCY CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓bw bintlba4 0 I SELFINSURED UARANTEE 0 3 INSURANCE [__j 4 SURETY BOND 5 LETTER OF CREDIT EVS EXEMPTION Q W 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 USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III.E THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY CO®N JURISDICTION# FACILITY O LOCATION CODE -OPTIONAL CENSUS TR a -OP L SUPVISOR-DIST ICT CGDE -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 FORM A(6.91) `�L FOR