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• auu x STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDG., q UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A C�l,e4na�" COMPLETE THIS FORM FOR EACH FACILrrYISITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Lv7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF LI NAME NAMEOFOPERATOR ADD NEA TC&OSSSTR PPACELp(OPTIONAL) CITU NA SATE K ZIP CCO9g rr�^ SITE PHONE# TH AREA CODE CAI/ BOX %J� (l !1I TO INDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP [=1 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY DISTRICTS TV PE OF BUSINESS O i GAS STATION 2 DISTRIBUTOR ❑ pESE IF RVATION #OF TAN AT SITE E.P.A. I.D.A(optional) O 3 FARM O 4 PROCESSOR 0 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 A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON�*WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME ` CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL E-1 LOCALAGENCY L-1 STATEEAGENCY 0 CORPORATION O PARTNERSHIP E-1 COUNTY-AGENCY [—I FEDERAL-AGENCY CITY NAME 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 bindicate 0 INDIVIDUAL 0 LOCAL-AGENCY L__1 STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME - - - STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION U7STpSTORRAGGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. 4 4 TY(TK) HQ -LLQ Ll_YL-II L71_� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED ✓ boxtc indicate [] 1 SELF INSURED GUARANTEE 0 3 INSURANCE E-1 4 SURETY BOND I� 5 LETTER OF CREDIT 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. II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 39 o90 1==139 LOCATION COD - PTIONAL ICENSUG Rgp'n,-OP7fONAL SUPVIS R-DI TRICT CODE -OPTIONAL //J I/ THIS FORM MUST BE ACCOMPANIED BY AT LEAST((1)))OO/R MORE PERMIT APPLICATION- FOR B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A 112-9n FILE THIS FORM WrTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO S 0 0 7 FORDOK