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i L STATE OF CAUFORNIIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILRY1SRE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE r al4b I. FACILRYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED ME F ATDR r�O Q�G DBA OR FACILITY NAME ` `A 4 (2>e4 N STC OSS STREET PARCELII(WiUNAU ADDRESS G R, F I r SI PHONEl WITH PREA STATE ZIPCADE aoglo�� `�� CITY NA / / _ CA ✓ BO% INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY ED COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' CORPORATION TOINDICATE DLSTRCTS' _ .N owner d UST is a pubec ency,mrrVlde the tollcwbg:near A SYPOIV60r d dNMWn,section,or oXim whk�opwates the !OF TANKS AT SITE E.P.A. I.O.!(apfimsp TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR E:::) RESERVATI ON ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (SECONDARY)-optional EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST.FIRST) PHON !WIT H R COD DAYS: NAME(LAST'FIRST) CODE PHONE i WITH AREA L/(!_ PHONE l WITH AREA CODE NIGHTS: NAME(CAGY,FI ST) PHO l WIT AREA CODE NKiHT3: NAME(LAST.FIRST) If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME ✓ OoxnbtlkNe INDIVIDUAL D LOCA4AGENCY OSTATE-AGENCY MAILINGOR STREETADDRESS 000RPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL#GENCY STATE ZIP CODE PHONE!WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION FNAMEOFOYVNER ✓ bu064 He INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY OR STREET ADDRESS (]CORPORATN)N O PARTNEnSWP CWMY 0.GENCY FEDERAL#GENC--- — -- STATE ZIP CODE PHONE l WITH AREA CODE E IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. (TK) HQ 4 4- - b V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED 1 SELF INSURED "2 GUARANTEE =3 INSURANCE O 4 SURETY ND ✓bw bindkW 5 LETTER OF CflEIXT ED E%EMPnON I3 go OTHER C 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: L El II.D 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 8 SIGNED) OWNER'STITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY G a COUNTY! JTU--R-IS�D�ICTION! FACILITY i LOCATION CODE -OPT CENSUS ! -OPT NAL SUPVISOR-DISTRK:T CODE -U°�� 0 1 3 , 4Do8 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IIFORMATIONOtILY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOiomMRO FORM A(3'63)