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STATE OF CALIFORNIA V STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ; r� COMPLETE THIS FORM FOR EACHLRYISITE o MARK ONLY ❑ 1 NEW PERMIT F--13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE ONE I71 TEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE ']J I. FACILITY/SITE INF &ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCEL N IOPTIDNAU a3s�7s „ � ,e� CITY NAMEr STATE ZIP CODE SITE PHONE#WITH AREA CODE w v hkrot� CA 209 -YKb /3Ys- BOX TO INDICATE _--�INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY []COUNTYAGENCY I]STATE-AGENCY (] FEDERI LAGENCY DISTRICTS TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN s OF TANKS AT SITE E.P.A. L D.•(apknal) RESERVATION 3 FARM Q A PROCESSOR Q 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) NIGHTS:NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA rnnF II. PROPERTY OWNER INFOR ION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ EmbinE Q INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY u ry`�J Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 V MAILING OR STREET ADDRESS 4 INDIVIDUAL (] LOCAL AGENCY Q STATE-AGENCY �I"�✓'^D CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 44 - L L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ bNAkm Q 1 SELF-INSURED a 2 GUARANTEE O 3 INSURANCE O 4 SURETY SONO 5 LETTEROFCREDIT (]6 EXEMPnON Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL❑ IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY A \ F317 EI= LOCATION CODE -OPTKINAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OP7IOA41L 2- ' —' 6 C-0 r�`� f � THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. FORM A(S91) �� fOR6013 5