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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i T: UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE ^•o,,,aa,,,.' MARK ONLY O I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE ITEM E::] 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE C� 1. FACILITY/SITE INFORMATION dt ADDRESS•(MUST BE COMPLETED) ✓ DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEARESTCRO STREET PARCEL (OPr s G.- i -rL-C)y/ CITY NAME STATE I DR CODE SITE PHONE a WITH AREA CODE � CA 5' TO INDICATE O CORPORATION I1 INDIVIDUAL O PARTNERSHIP LOCALAGENCY ED COUNrYAGENCY• O STATE-AGENCY• gA4A(iENeY• I owner W UST u a pubic agency.mrtplele the bbowinp:name W Supervisor of oblebn,sectDSTPoCTS'bn,m orrice which Operates the UST TYPE OF BUSINESS O t GASSTATION 0 2 DISTRIBRESEUTOR ✓ IF RVINDIAN aoF TANS,S AT SITE E.P.A. I.D.a(aplimae ATION U Q 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(UST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bas 0kxkm INDIVIDUAL LOCAL-AGENCY ED STATE-AGENCY CORPORATION O PARTNERSHIP COUHTYAGENCY = FEDEM4AGENCV CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF NER CARE OF ADDRESS INFORMATION � e MAILING OR STREET ADDREESS ✓ but lMicele INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY 5 C' G— S CORPORATION PARTNERSHIP COUMYAGENCY FEDERAAGENCY CITY NAM SQWkiot lir h1 STATE ZIP COD , PHONE a WITH AREA CODE ? OL 17Z BOARD OF EQUALIZATION-UST STORAGE FE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HO M44- -[Lj:r= V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ bm b i�gicale 0 1 SELF INSURED 2 GUARANTEE Q 3 INSURANCE =1 4 SURETYBOND E__1 5 LETTEROFCREOT Q S EXEMPTION 0 W 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.O It.O 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) OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY JURISDICTION# FACILITY* LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISGR-DI ICT CODE -OPTIONAL — ^ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE NFORMATKON ONLY. FORM A(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS WRIWSART