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a STATE OF CALIFORNIASTATE WATER RESOUflCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM AI✓1COMPLETE THIS FORM FOR EACH LrrYISITE MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT 3115 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM =1 2 INTERIM PERMIT = 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 9 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMENAME OF OPERATOR ADDRESS - NEAREST CROSS STREET PARCEL I IOPTIONAW Q "J _ CIN NAME STATE ZIP CODE SITE PHONE S WITH AREA CODE ,S-Ip CAI/ BOX Sao/ T NDICATE O CORPORATION (]INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR E—] ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION 1 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS p EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) 5CAUfer r -9 S5 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONF H. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME Co CARE OF ADDRESS INFORMATION MAILING OR REET ADDRESS ✓bubinEbab = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY y O 3 =CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERALAGENCY CITY NAME `� / STS w ZIP CODE PHONE s WITH AREA CODE S J lova c4- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION u ,-e a MAILING OR STREET ADDRESS ✓ boa b Indicate D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY O CORPORATION PARTNERSHIP Q COUNTY-AGENCY 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) HO [-4-F4-]- V. 4 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boy ID rdiOW 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND D 5 LETTEROFCREOIT D 6 EXEMPTION = 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 11.D III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACIL"# FS17 LOCATION CGDE -OPttONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRIC -OPT/O 3a THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OOOFFAF SITE INFORMATION ONLY. FORM AIS91) 'J//"V 7S