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~� STATE OF CALIFORNIA '411110 STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NA NAME OF OPERATOR ADDRESS _ NEAREST CROSS STREET Z' = ) CITY NAME STATE ZIP CODE H AREA CODE CA ✓BOX CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY OCOUNTY-AGENCY' OQ FEDERAL-AGENCY•TO INDICATE DISTRICTSka9ebrCa ,0mPMNbebbwbg name o(s rl sol 01 division,WINXI we lcex mch oea2les Ne UST ESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN ROF TANKS AT SITE pfn)nalJ RESERVATION 3 FARM a A PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) 9 PHONE#WITH AREA CODE 4 DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE o NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION t MAILING OR STREET ADDRESS ✓ b'v7We 0INDMDUAL CD LOCAL AGENCY O STATE-AGENCY a CORPORATION O PARTNERSHIP O CDUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE I LP CODE PH E R WITH AREA CODE L S 3 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION *t�!,LC. T 1 Z 17 5 MAILING OR STREET ADDRESS ✓ boa loiMbale Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AGE# CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE HO MWITH AREA CODE N T4\7 E v2- 3 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions rise. TY(TK) HQ F4-74- - V. PETROLEU UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓yoyby�e 1 SELF-INSURED Q 2 GUARANTEE Q3 INSURANCE ED A SURETY BOND O 5 LETTERoFCREDR 0 9 EXEMPTION ED 7 STATE O a STATE FUND S CHIS FINANCIAL OFFICER LEM =9 STATE FUND 6 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.❑ 11. III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR C _ L L LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY 9 EE LOCATION CODE -OPTIONAL CENSUS TRACT# -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. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)