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e,eU" c, STATEOFCAUFORMA �` c ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A = n, COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY D I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR ILI NAME NAME OF OPERA ` W ADDRESS —m 11112;� NEAREST CROSS STREET PARCEL#;OPTIONAL) till/ CITY NAMSTAcA ZIP COOS SITE PHONE#WI AREA CODE BOX T NDIC TE Cl CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' DISTRICTS' 0STATE-AGENCY' OFEDERAL-AGENCY' 'If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which Operates the UST TYPE OF BUS}NESS t GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(apt or alJ [] 3 FARM 0 4 PROCESSOR 5 OTHERFOR RESERVATION TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF DRESS INFO MAT 13 MAILING OR ST ET ADD ESS ✓ boxbindkate ff INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY 1 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY C17Y NA STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b indicale INDIVIDUAL Q LOCAL-AGENCY 0 [� STATE-AGENCY CORPORATION FEDERAL-AGENCY PARTNERSHIP COUNTY-AGENCY 0 CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIndicate I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE L7] 4 SURETYBONo 5 LETTER OF CREDIT 0 G EXEMPTION 0 99 OTHER VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. ill.E 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) OWNERS TITLE DATE MONTNIDAY/YEAR LOCAL AGENCY USE ONLY -Kr__? COUmNTY# JURISDICTION# FACILITY# 3Gj�j lam' LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 71 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 UNDERGROU STORAGE TANK REGULATIONS FORMA{3163) .