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STATE OFCALIFOgWA .° STATE WATER RESOURCES CONTROL BOARD + UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A `n� COMPLETE THIS FORM FOR EACH FACILITY/SITE ��I,IUnM�� MARK ONLY F-1 t NEW PERMIT 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED S1TE ONE REM O 2 INTERIM PERMIT Q & AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) r)RA OR FACILITY NAME NAME OF OPER ATOfl r T� � ADDRESS LL NEARESTCg053 STREETML—JSTATE-AGENCY' OPTp �ZJ Al. CITY NAME STA�ZIPCODEE a WITH AREA COOSe T NDI ATE CORPORATION I�INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTYCY' O FEDERAL-AGENCY'N canner of UST la a public agen m e DISTRICTS'ey, mplete the IoNowin :name o/Su rvkor of tlNuIon.sed'bn,or office which operates the UST TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN aOFRESEATION I.D.a(optional)Q 3 FARM Q a PROCESSOR � 5 OTHER O RTRUSTVLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,F ST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONEN WITH AREA CODE IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boa blMka4 Q INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY E-1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 4942!r_ C III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION r iAdl seri MAILING OR STREET ADDRESS ✓ boa b Indicate E-1 INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY /m// C4- - / 1=1 CORPORATION I= PARTNERSHIP ID COUNTY AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIPCODE PHONEa ITH AREA ODE GDl !J IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL HESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ tw+bindbaN 0 1 SELF-INSURED L:J 2 GUARANTEE Q 3 INSURANCE 1:715 LETTEROFCREDT E]6 EXEMPTION 0 a SURETYBOND � %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: I.[�] II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION u FACILITY• LOCATION CODE -OPTIONAL CENSUS TRACTi -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL D r9 5-,94> 3_719 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 FORM A 131x3) 0 • FOf10037Ag7