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` STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A os COMPLETE THIS FORM FOR EACH CILITY/SITE C4k Ira Iq MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SIT ONE rrEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA Ofj ILA NA CZE NAME �'O��Rp��O 1�!r�.� ADDRESS ,. NEAREST CROSS STREET PARCEL 0(OPTIONAL) V CITY NAM STATE ZIP I PE SITE PHONE a WITH AREA CODE CA BOX To INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY•AGENCY' STATE-AGENCY' [_1 FEDERAL-AGENCY' DISTRICTS' I1 owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF T AT SITE E.P.A. I.D.0(optional) RESERVATION 3 FARM 4 PROCESSOR = 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t+WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION [] PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE is WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - -� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE THOD(S) USED ✓ box bindicate (] 1 SELF-INSURED 2 GUARANTEE IV3 INSURANCE [:_1 4 SURETY BOND S LETTEROFCREDIT 0 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.0 II.[—] III.a 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) OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY#pK LOCATION61E -OPTIONAL CENSUS TRACE/ - IO,y4E SU -PVISOR-DISTRICT D OP / L.1� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO71 , FORMA(3/93) 7;�4