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iSTATi OF CALIFORNIA �� / STATE WATER RESOURCES CONTROL BOARD W.� UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , �F COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•a�"'' MARK ONLY F--] 1 NEW PERMIT O 3 RENEWAL PERMIT r--j S CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE REM F7 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] e TEMPORARY SITE CLOSURE s 1. FACILITY/SITE INFOIRMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ,Of_ ADDRESS ry NEAREST CROSS STREET PARCEL 0(OPrONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA TOIN Box CORPORATION INDIVOUAL PARTNERSHIP 2 =-ADISTRL-AGENCY 0 CWNrY-AGENCY' STATE-AGENCY' FEDERALAGENCY' • CTSA N owner of UST Is a public agency.amide the following:narne of Supervisor of dhhbn,section.or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RE/ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.#(option) [] 3 FARM Q 4 PROCESSOR E2(ER OR 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 S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAMCARE OF ADDRESS INFORMATION VVk . L) . to . MAILING STREET ADDRESS ✓Dox bIMk44 l� INDIVIDUAL LOCAL-AGENCY E::] STATE-AGENCY d'So0 ilio 1Jto r. CD CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCI' 0 FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE k Ca f 5zo III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bWb4tliceM Q INDIVIDUAL LOCAL AGENCY STATE-AGENCY f�CORPORATION PARTNERSHIP L—I COUNTYAGENCY f-1 FEDERALAGENCY 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 M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓bo:b40ktle I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT O e EXEMPTION O 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: 1.0 11. 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 a SIGNED) OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# ,(�/� FACILITY# ® U 2 3 LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR•DIS ICT CODE -OPTIONAL �l 9-8- S- a 3-9 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 FaaoN��T FORM A(393) ial y�� y