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STATE OF CAUFORNIA a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOO EACH FACILRYISITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION xPERMANENTLY CLOSE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT [�] e TEMPORARY SITE CLOSURE �Q I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFW NAME R I Cft NAME OF OPERATOR ADERE S h O NEA S C o*S PARCEL a IOPrDNAU tOJ S. CITYSTATE ZIP CODE SITE PHONE i WITH AREA CODE NAME ,-, V CA T.1 Box CORPORATION O INDIVIDUAL � PARTNERSHIP LOCAL-AGENCY Q COUNfY-AGENCY' STATE-AGENCY• I�FEDENAL-AGDCY' DISTRICTS' •I owner d UST is a public agency,oo plete the following:name of Supervisor of division,section,or oNica which operates the UST TYPE OF BUSINESS 0 1 GAS STATIONQ 2 DISTRIBUTOR REV IF SERVNDDION i OF TANKS AT SITE E.P.A. I.D.a(cpflana) Q 3 FARM 0 4 PROCESSOfl 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME_ CARE OF ADDRESS INFORMATION 149 1 MAILING OR STREET ADDRESS ✓box bintlbaN INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY D CORPORATION ED PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bos 110bM1&a1 D INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY =CORPORATION D PARTNERSHIP CGUNTYAGENCY 0 FEDERAL-AGENCY CITY 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) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓�X, 0 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE Q 4 SUR ETYBOND O 5 LETTEROFCREDIT 0 a 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: 1.[�] it 0 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED It SIGNED) OWNER'S TITLE DATE MONTH/DAVNEAR LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION 0 FACILITY• Z LOCATION�ODE -0PTX)NAL CENSUSTRACTi -OP SUPVISOR-DISTRICT CODE -OPTIONAL / 3: cs THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- F R B,ULLESSTHIS IS A CHANGE OF SITE u 14W, FORMA MA C LLY- OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM (393) H'OR9WLlA7