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STATE OF CALIFORNIA .` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ' COMPLETE THIS FORM FOR EACH FACIUTYISITE PERMIT NEW 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO MARK ONLY 1 o o a ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION IT ADDRESS-(MUST BE COMPLETED) DBAOR FACILDV NAME � NAMEOFOPERATOR ADDR[EESSt� N ESTCRO STREET PARCELa(OPrIONAU TV , 9 CITY NAME STATE ZIP SQDE SITE PHONE i WITH AREA CODE © cK CA rJi TO INIDCATE O CORPORATION Q INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY OCAL-AGENCY O COUNTY-AGENCY' Q STATE-AGENCY' D FEDERAL-AGENCY' •If owner of UST Is a public agency,complete the f tUmIng:name of Supervisor W oNlelon,section,or office whish operates the UST TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR / IF INDIAN RESERVATION a OF TANKS AT SITE I E.P.A. I.D.0 rophanarl Q 3 FARM Q 4 PROCESSOR 6 OTHER OR TRUSTLANDS 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 a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box 106dbate 0INDIVIDUAL LOCAL AGENCY STATE-AGENCY D CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME 9TATE ZIP CODE PHONE a WITH AREA CODE 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxbi-dkM = INDIVIDUAL El LOCAL-AGENCY Q STATE-AGENCY O CORPORATION = PARTNERSHIP Q COUNTY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a 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 ✓box bintlbde 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND O 5 LETTER OF CREDIT D 6 EXEMPTION O Ba 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: 1.0 II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAM E(PRINTED S SIGNED) OWNE R'S TITLE DATE MONTHMAYNEAR LOCAL AGENCY USE ONLY COUNTYA, JURISDICTION# FACILITY# LOCATIONOODE-OPTIONAL CENSUSTRACCTT#,-G�p�TWNAL SUPVISODR-DISTRICT�gOE-OPTIONAL THIS FORM MUST BE ACCOMPANIED BY ATLEAST(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 FORM A(3'83) FOR6e33AA7 go �j'/ a-- y5d�/z