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• � a STATEOFCAUFDRMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILTrY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT E:] 5 CHANGE OF INFORMATION E::] 7 PERMANENTLY CLOSED SITE ONE REM [_] 2 INTERIM PERMIT A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 0/ 1 I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) OBAORF CI N AME JJ, " 1DC" � NAMEOF P RTO lw Ow ADDRESS 'll'Y ✓NL_il NEAR ST O STREET/� PARCEL#(OPFIONAL) r/ CITY NAME + _ _ STATE ZIP DE SITE PHONE Y WITH AREA ODUE I/^OFY,/) CA Jl LOR OCAL-AGENCY TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 DISTRICTS' COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENCY' 'If owner d UST Is a public agency,mopiete the following:new of Supervisor of division,sedbn,ar office which operates,the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANIX6AT SITE E.P.A. I.D.#fopfknap RESERVATION /(/^ ❑ 3 FARM ❑ d PROCESSOR ❑ 5 OTHER OR 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 CA EOF ADDRESS INFORMA 10 _ V I MAILI F1 TREET RESSX 239 a _ -- ✓bo_0NICA =1INDIVIDUAL UXIALAGENCY O STATE-AGENCY CORPORATION = PARTNERSHIP COUNTY-AGENCY (l FEDERAL-AGENCY CITU ST 2�9 CODE PHONE#WITH AREA CODE 2 22- III. TANK OWNER INFORMATION•(MUST BE COMPLETE NAME OF OWNER CARE OF ADDRESS INFORMATION C/'I MA NG ORSTREE DRESS ✓boxbindioate D INDIVIDUAL ED LOCAL-AGENCY 0 STATE-A CY CORPORATION PARTNERSHIP Q COUNTY AGENCY 0 FEDERALAG Cy CITY NAK 0. ISTATE 9- z�9PHONE If WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9 16)322-9669 it questions arise. V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Wv birAKale D I SELF INSURED (]2 GUARANTEE 3 INSURANCE O 1 SURETY BOND 0 9 LETTEROFCREDIT 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Iorllis hacked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ IL H.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTWDAV/YEAR LOCAL AGENCY USE ONLY COUNTY39 JURISDICTION# 1 ' FACILITY ,J`,,I 'k q LOCATIONCGDb TIONAL CENSUSTRAC i1PTrN ty 9UPVISOR-DISTRICTCOy .; nnT r,3 l •,(_,1I FV THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE COFF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGr. FORMA(393) • FORM3AR7