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♦ 1 rxca" r ?� STATE OFCAUFOWllA w,• o STATE WATER RESOURCES CONTROL BOARD V UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A `•♦ ,> COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE 3 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA WE FACILITY NAME IFNAMEOFOPEHAIOR •V\ PAACELIIOPrgNAU ADDRESS NEAREST CROSS STREET CI N STATE ZIP CODE SITE PHONE AREA CODE CA 7T,lTS T 10 Nq AC TE I�CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY �COUNTY AGENCY' I�STATE-AGENCY' � FEDEPALAGENCY' DISTRICTS' 'N owner d UST Is a Public agency,conplde the following:name d Supervisor of d"ion,aectlon,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ,/ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(op(icnal) RESERVATION ❑ 3 FARM ❑ 4 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 IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME ....a � T CARE OF ADDRESS INFORMATION rMAILING OR STREET ADDR C.-44/t ✓ Dox blMkate INDIVIDUAL LOCALAGENCY ] STATE AGENCY Q� (]CORPORATION O PARTNERSHIP D COUNTY AGENCY ] FEDERAL TY NA STATE ZIP CODE_ PHONE#WITH AREA CODE (� s. I III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Dex b indicate E INDIVIDUAL 1 LOCAL-AGENCY ] STATE AGENCY I]CORPORATION O PARTNERSHIP (] COUNTY AGENCY ] FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓bm trintlkale L-1 1 SELF-INSURED 2 GUARANTEE ] 3 INSURANCE O 4 SURETYBOND O 5 LETTEROFCREDIT 6 EXEMPTION O N 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: I.❑ I. nSIII.❑ 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 COUNTY# JURISDICTION# FACILITY# jN v3E IM0161TV LOCATNGN&DD -OPTIONAL CENSU CTs -OPTIONAL SUPVISOR-DISSTRICT -OP7701ML THIS(FORM MUST BE ACCOMPANIED BY AT LEAST(C1))ORR�MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE WORWTION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) • ��' /FOROCI,MA7