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P44 • x t PUYERGROUND STATE OF CALIFORNIAoSTATE WATER RESOURCES CONTROL BOARDWog' :aY O STORAGE TANK PERMIT APPLICATION- FORM A >. _ , ; I�r COMPLETE THIS FORM FOR EACH FACILITYISTTE C'l4Ow"�� MARK ONLY �I 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE�?F-- ONE REM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ s TEMPORARY SITE CLOSURE I. FACILITY1SITE INFORMATION 81 ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY N ENAME OF OPERATOR - ADORES NEARESTCROSSSTREET PARCEL#(OPTIONAL) Aa55 g Qc- Yr a-41-Ii CITY NAME ` STATE ZIP COD SITE PHONE#WITH AREA CODE CA ✓ BOX COIPOAIOINDIVIDUALC:l PARTNERSHIP AECDERAL#GENC OINCATE GY' T OISTRICTS- •I owner d UST is a public agenry,comiese the 1060wing:name Of Supervisor d dlvibn,section,or office whch operm"the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR flESEgyATTION #OF TANKS AT SITE E.P.A. I.D.#(gNronaQ O 3 FARM Q A PROCESSOR 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NA E(LAST,FIRST) Ch PHONE#WITH A A CODEGAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 1-3 NIGHTS: NAME(LAST,FIR PH #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COO: II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME n ^ ..T CARE OF R INFORMATIO MAILING ORS STREET ADOR 1 1 �I' fCORPORATION pl Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL CITY NAME ^ • t ZIP ODS PH N�#JW AREA CQgE ik '� Ln III. TANK OWNER INFORMATION•(MUST BE COMPLETED) l/ (ry NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box binOi Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY 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 F4-14 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box bindkae = I SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND Q 5 LETrER0FCRE0n 6 EXEMPTION Q 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.' III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT OWNER'SNAME(PRINTED SIGNED) OWNER'S TRUE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDKTK)N It FACILITY# LOCATION CODE -OPTIONAL CENSUS TRAC OP HALO SUPVISOR—DW ICT -OF NAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION- F0RU A ALW TRStS**7dHANGE OF SITE WORMATION OILY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM FORM AWIN) . '�1 L- ; ��/ FON6m7AR1 .... � 7/& �.CJ r C/