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a SIATEOFCALIFORWASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n ❑ S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACIL91Y NAME I\ r NAME OF OPERATOR I _31 _ tj PARCEL#(OPrpNAL) ES AD S -� o NEARESTCROSS STREET tZIUP�j CITY NAME ii STATECODE SITE PHONE a WITH AREA CODE Gc1 .5 t ✓ Box Q CORPORATION I7C1 INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY I�COUNTY-AGENCY' E3 STATE.AGENCY' O FEDERALAGENCY' TO INDICATE /�\ DISTRICTS' 'II owner of UST Is a public ageneY,ocr plete the following:name of Supervkor of oNlebn,section,or oNice which operates the UST TANKS AT SITE E.P.A. I.O.#(gxknelj TYPE OF BUSINESS Q 1 GAS STATION ❑ 2 DISTRIBUTOR t ❑ RESERVADION #OF Q 3 FARM O 4 PROCESSOR 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILI GOBS BEET AD S ✓ #0°b Indicate INDIVIDUAL LOCAL-AGENCY STATE AGENCY )( CORPORATION 'fO PARTNERSHIP OCOUNTY-AGENCY FEDERAL-AGENCY CITY NAM STATE ZIP E PHONE a WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION -S I'Yl J GY MAILING OR STREET ADDRESS ✓ bmbinebaN = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY (]CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ M44- -L�1� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Dor bindcMe = I SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE <SURETY BONG O 5 LETTEROFCREDIT O 6 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 II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.D II. III. 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY C�OODU-NTTTYYg�# JURISDICTION• FACJLrrY-+►-.----... LOCATION CODE -OPTIONAL CENSUS TRACT a •OPTIONAL SUPVISOR-DISTRICT mai THIS 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 UNDERGROUND STORAGE TANK REGULATIONS FOROWMA7 FORM A(3193) • •