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• �. tWe f t STATE OF CALIFORWA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITYISRE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE i0 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR z� ADDRESS NEAREST CROSS STREET PAnCEL 1(OPr10NAL)CITY NAME STATE ZIP CODE I SITE PHONE a WITH AREA CODE I/ BOX I CA 9 Ug —30 TOINDCATE O CORPORATION D INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' If oxner of UST lea public y a DISTRICTS' p agency.cornplele the followln :name of Su rvaor of dWkion.Hill or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a fccou l) ❑ RESERVATION Q 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: AME(LAST,f IRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 36�- 04T I NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA COIdh NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Zo9 36,Q— 72.�D 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION b"Y / MAILING OR STREETADDRE53 ✓ bo�mindbale E-11INDIVIDUAL = LOCALAGENCY 0 STATEAGENCY S% CORPORATION 0 PARTNERSHIP O COUNTY'AGENCY 0 FEDERAL AGENCY CITY NAME S ATE ZIP CODE PHONE a WITH AREA CODE G o4 If % oq — a III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Goa/ I, MAILING OR STREET A ✓ box bindicate D INDIVIDUAL O LOCALO AGENCY STATE AGENCY O 5�DDRESS % ORPORATION O PARTNERSHIP O COUNTY AGENCYEJ FEOERALAGENCY CITY NAME STAZIP CODE PHONE If WITH AREA CODE av 0i fie -/D z-4 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916))322-9669 if questions arise. TY(TK) HQ F4]-4]- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bop to Indicate 1 SELF INSURED L-j 2 GUARANTEE 0 3INSURANCE D 5 LETfEROFCREDT A SUREN BOND 6 EXEMPTION I�5e 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. 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 TRLE DATE MONTWDAY11'EAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# aTqj Ll I 1119-17 LOCATION CODE -OPTIONAL CENSUS TRACT SUPVISOR-DISTRICT CODE . o y THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE Pi APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 4kFORaml