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•_� STATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACHFACILITY/SITE MARKONLY t NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM 0 2 INTERIM PERMIT 0 4 AMEND Is 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPrgNAy CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE onl CA J BoX0 CORPORATION INDIVIDUAL ED PARTNERSHIP O LOCAL-AGENCY O COUKrY#GENCY` ED STATE-AGENCY' O FEDERAL#GENCV' TDINDICATE DISTRICTS' -ff center of UST is a public agency,complete the following:name of Supemeor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O RESERV TION #OF TANKS AT SITE E.P.A. I.O.s(aplarMl/ Q 3 FARM 4 PROCESSOR = 6 OTHER OR TRUST LAN DS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE DAV3: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONES WITH AREA CODE NKiHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARED ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓I)DICbNSCUO O INDIVIDUAL O LOCAL AGENCY D STATE-AGENCY O 7 0 CORPORATION 0 PNRNERSMP = COUNTY AGENCY O FEDEML#GENCY CITY NAME / STATE ZIP CODE ONE s TH AREA CO ,Q1 Z) z2 9 57 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER/.q, CARE OF ADDRESS INFORMATION c�� MAILING OR STREET ADDRESS Q `/ Oor budaab O INDIVIDUAL O LOCAL-AGENCY DSTATE-AGENCY - 8 ��.-. 75:5 CORPORATION O PARTNERSHIP C=]COUNTY#GENCY 0 FEDERAL#GENCY STATS ZIP CODE HONE s WITH AREA CIT/ 4' Y/ S74` qz/S 7 707 .�-7--/ 7 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-T4-1- V. 4- -V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED bBdkib O 1 SELF INSURED O 2 GUARANTEE O 3 INSURANCE I�4 SURETY BOND O 5 LETTER OF CREDIT O 6 EXEMPTION [�]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.O 11.LkT III.O 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/DAYIYEAR LOCAL AGENCY USE ONLY FI1?,$D b 7 3 o COUNTY x JURISDICTION a 5- o S 71-7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL o 7 1 Z3. 90 13ZD 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 FORMA(393) ;k%VA7v"