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�pW- e STATE OF CALIFORNIA .`- ` STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A '�� COMPLETE THIS FORM FOR EACH FACILITY/SITE '�,�„a-,,,. MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 0 S CHANGE OF INFORMATION O 7 PERMANENTLY CLO ONE REM Q 2 INTERIM PERMIT 0 • AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 71 I. FACILITY/SITE INFORMATION 8 ADDRESS•(MUST BE COMPLETED) MMA 09 FACILITY NAME NAMEOFOPERATOR ADDRESS NEARESTCROSS STREET PARCEL#(OPTIONAL) So CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE r e A I ✓Box TO INDICATE O CORPORATION 0 INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY O COUNTYAGENCY' O STATE.AGENCY. I1 FEDEMLAGENCY' DISI miter of UST Is a public agency,mrrpMle the folbWing:na of Supervisor of divbbn,section,W oNHs Whbh Operates the UST TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOq ✓ IF INDIAN #OFT�KS AT SITE E.P.A 1.0.#(cpe w) 3 FARM Q 0 PROCESSOR HER fi OT0 RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE 3 NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA UUUt NIGHTS: NAME(AST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDR SS ✓boxbinErLs 0 INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY T p CORPORATION O PARTNERSHIP = COUNTYAMNCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET AD ESS� , ✓boM b916bW 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 5 /V - A_j E LSL. w D /r � O CORPORATION PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 9fzr/a IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓bor 10IWCale O 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE a A SURETY BOND 5 LETTEROFCREDT 6 EXEMPTION Q 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: 1.0 II.Q In.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION# FACILITY 7 Z� �5X* LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL �54z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFO TIN ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) FOg99J1A477 s