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� '4e�ya f STATE OF CALIFORNIA ,� •, STATE WATER RESOURCES CONTROL BOARD 3 ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� "° COMPLETE THIS FORM FOR EACH FACILITY/SITE �.oew�- D MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ / AMENDED PERMIT 16"S TEMPORARY SITE CLOSURE I. FACILITWSITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR f�CILITY NAME '414 NAMEOFrRAOTOt e q ' �� / ADDRESS NEARS CROSSSTRE I- PAR 0(OPrKNUy S rC�It OaK CITY NAME STATE ZIP SITE PHONES WITH AREA CA D 7- 5 Box 701Nq TE O CORPORATION Q INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY• O STATEAGFNCY' O FEDEMLAWNCY' X owner of UST is a public agency,compete the fosming:narne of SupmNor of division,sect n, Dake DISTRICTS' operates tlr UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOfl ❑ ✓ IF INDIAN I OF TANKS ATSITE E.P.A. I.D.I(GpffaWJ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRSTI, PHONE WITHAJREAOODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(6,ST.FIRST) PHONE I TH AREA CODENIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA OODE IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME �l CAREOF IOD ESS I FORMATION �-� I) - . , i i .LNC , m MAILING OR STR ADORE St n ^ ,1� ✓Eu bintlkaM L-j INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION 11 PARTNERSMP Q COUKTYAGENCY FEDEPALAGENCY CITY N!r Q A ZIP PHONEI WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE CO PLETED) NAME OF OWNER T CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS f 0 ✓ hoabeHkAts = INDIVIDUAL I]LOCAL-AGENCY STATE-AGENCY _ O CORPORATION O PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCYCRT NAME STATE ZIP CODE PHONE I WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- -j V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eor 0i onto E-1 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O 1 SURETY BDND O 5 LETTER OF CREDIT =8 EXEMPTION NI OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I orr_II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II- isIII.❑ 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 MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY p JURISDICTION• LOCATION CODE -OPTIONALCENSUS TRACTI -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY, FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOPOOJ)AAi