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n' STATE OF CALIFORNIA ' STATE WATER RESOURCES CONTROL BOARD '�g - :8 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A . ,, s COMPLETE THIS FORM FOR EACH FACILITYISITE `"1ee"'� MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEOF PERATOR - ADDRESS NEAREST CROSS STREET PMCELa(OPTIONAU DE CITU NAME STATECA ZIP GO SI O SIT HONES'ITH ARZE,iCA ✓ BDA CORPORATION � INDIVIDUAL TNERSHIP LOCAL-AGENCY ��COUNTY-AGENCY' 0 STATE-AGENCY' E FEDERAL-AGENCY TOIN Box DISTRICTS' II owner of UST Is a public agency.wnplete the following:name of Supervisor of eiVsbn,section,or office which operates the UST TYPE OF BUSINESS E),kf`GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS SITE I E.P.A. I.D.a rcptionall RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS VAME(LAST,FIRST) E a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE o9J a3�o NIGHT - NAME(LAST,FIR T G� ONEc#W WIT TH=RE NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE II. PROPERTY OWNER NF RMATION- MUST BE COMPLETED NAMEG OR STREE $/ 1 CARE OF ADDRESS INFORMATION y T ADD MAILINRESS Cff ✓ boxbirdkab = INDIVIDUAL = LOCAL-AGENCY OSTATE-AGENCY 0 S / =CORPORATION ARTNEASHIP = COUMYAGENCY Q FEDERAL AGENCY z:= CITU NAME 'u^ d STA ZIP COD ON a WITH AREA CODE Z� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER AX p t CARE OF ADDRESS INFORMATION / REE TIL MAILING ORS REE TADDRESS ✓ box binticLe INDIVIDUAL � LOCAL (]STATEAGENCY 0 CORPORATION PARTNERSHIP COUNTY AGENCY 0 FEDERAL AGENCY CITY NAME STATE ZIP PHONE � YjT��Z DZJ7/C! IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. JJ TY(TK) HQ F4]4- - L7 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicde t SELF INSURED 2 GUMANTEE [::] 3INSURANCE O 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION =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. IL❑ IIL❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYlYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# F�A�CI/LIT�Y!#�� LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL Z� 90 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THE IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORo033A.R7 FORM A(393)