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• • yOVA p STATE OF CALIFORNIA `. STATE WATER RESOURCES CONTROL BOARD iy o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� v; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' z;-& I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOB FACILITYNAME Q�• NAME OF OPERATOR ADDRESS tNEAREESTSS STREETPAflCEU(OPTIONAL)� O CITU NAMEZIP CODE SITE PHONE#WITH AREA CODE %'1jZi; � ✓ Box TO INDICATE CORPORATION (] INDIVIDUAL [=1 PARTNERSHIP E-1 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IFERVINDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) E:] 3 FARM ❑ 4 PROCESSOR RESATION 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRS PONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) Zo`1 Z22—$Z)b NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NA �� CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS �J //�� ✓ box bintlicala INOIVIOUAL LOCA4AGENCV 44 [71STATE-AGENCY / / • 0 CORPORATION I] PARTNERSHIP 0 COUNTY-AGENCY [711 FEDERAL-AGENCY CIW'a4M& STATE ZIP CODEDE HONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NA F OW/� P CARE OF ADDRESS INFORMATION MAILING O STREET ADDRESS ✓box 0 micab 0 INDIVIDUAL 0 LOCAL-AGENCY (�STATE-AGENCY 171 !a sq T O CORPORATION (] PARTCOUNTY-AGENCY D FEDERAL-AGENCY CI E 5i D STA 21P CO ONE# ITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L4L� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindiI = I SELF INSURED 0 2 GUARANTEE =1 3 INSURANCE (]A SUREtt BOND 5 LETTER OF CREDIT (]6 EXEMPTION E-1 0 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.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3 6� 1010 16U04 �ar�9 - -- --- LO N CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 2 I `VJ-Ls/• THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12-el) FILE THIS FORM WITH THE CAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK R CATIONS • FOR0035A