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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 0 EW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA RFACILITY NAME ` NAMEOFOPERATOR c 4 ADDRESS L NEAREST CROSS STREET PARCEL#(OWIONAU re^oA `- CITY NAME STATE ZIP CODE SITE ONES WITH AREA CODE s CA 43 - s o0 Box TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL'ADENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERALAGENCY' 'A owner of UST Is a public agency, DISTRICTS' ry,wrrplela the IOAowing:name of Supervisor of Elvisbn,section,or office which operates the UST TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE 7-P TAI 0 3 FARM 4 PROCESSOR 0 5 OTHER RESERVATION Ofl TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Ooebintlkale Q INDIVIDUAL QLOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNtYrAOENCY Q FIEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION C G S S MAILING OR STREET ADDRESS ✓ bwb4bbeta Q INDIVIDUAL Q LOLL-AGENCY Q STATE AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#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 ✓box bintlbale Q I SELF-INSURED Q 2 GUARANTEE Q 3 NSURAWE Q 4ETYBOND Q 5 LETTEROFCREDT Q S EXEMPTION I!n9B OTHER NAr.1' VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bqx I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LE7f IL O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED B SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTYN JURISDICTION# -fACRft11# Q �yr - ® LOCATION CODE -OPTIONAL CENSUS TRACT# -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. FORMA OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS (353) FOHceJ7A-F"