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STATE OF CAUFORWA :� o STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , s (/ COMPLETE THIS FORM FOR EACH F YISITIE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL E ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE s I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS VCM NEAREST ROSSSTBEET P�ELI(OPT000 CITY NAME STATE ZIP CODE SITE PHONE I WITH AREA CODE iNyrl CA Box CORPORATION O INDIVU0 PARTNERSHIP LOC -AGENCY COUNTY WENCY' STATE-AGENCY' 0 FEOUMLAGENCY' T DISTRICTS' N otter of UST Is a publicagency.complete the following;name d Supervisor of division,section,or duce which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓ IF INDIAN s OF TANKS AT SITE E.P.A I.D.s(optimal) RESERVATION 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(UST,FIRST) PHONE I WITH AREA CODE DAYS: NAME BAST,FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bubinOkaN 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION = PARTNERSHIP O COUNTYAGENCY El FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓6a 0Indicat INDIVIDUAL LOCAL-AGENCY STATE AGENCY 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ bu tory, 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND O 5 LETTEROFCREDT O 8 EXEMPTION 99 OTHER V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles d.'` CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE ,IS TRUE AND CORRECT OWNER'S NAME(PRINTED A SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR 6- -q LOCAL AGENCY USE ONLY W 141 / C�B JURIS i F(I� �e 3(p�o I i we YTI LOCATION CODE -OP 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. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS l FORMA(393) - "\�� N