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%0001 STATE OF CALIFORNIA 0 4 STATE WATER RESOURCES CONTROL BOARD i�,� UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A ,, COMPLETE THIS FORM FOR EACH FACILITY/SITE "N 1 NEW PERMIT F_-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE MARK ONLY ❑ ONE ITEM F72 INTERIM PERMIT E:] 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR Cl fN NAME NAME OF OPERATOR ADDRE4�s NEAREST CROSS STREET PARCEL Ir(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S O C- 4� CA 9 ✓BOX O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL.AGENCY O COUNTY-AGENCY' I]STATE-AGENCY' M FEDERAL-AGENCY' TO INDICATE DISTRICTS '&osmwdUSTbapubkapncy,m lg thebbwYl rramed s,,wiwrd drrem,section or otrm which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ❑ RESwl IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(apfio m0 Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS NAME(LAST.FIRST) PHONE a W TH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE S X09 — 894 NIGHTS: NAME(LAST,FIRST) PHONE M TH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION G1i ,GeS MAILING OR STREETADDRES ✓ butairdw:e INDIVIDUAL a LOCAL-AGENCY STATE AGENCY D CORPORATION D PARTNERSHIP ] COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME a STATE ZIP ODE PHONE#WITH AREA CODE - 5 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ buctokidule O INDIVIDUAL O LOCAL AGENCY C] STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 744- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boabidme 1 SELF-INSURED O 2 GUARANTEE D 3 INSURANCE I1 4 SUREIYBOND O 5 LETTEROFCREDIT =8 EXEMPTION O T STATE FUND e STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 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: I. II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHYDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE - CENSUS TRACTM -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. FORM A(695) OWNER MUST FILE THIS FORTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRr�STORAGE TANK REGULATIONS 4- g- q9 eAA&