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STATE OF CALIFORNIA OD STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FA YISITE EMARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SRE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE Sb I. FACILITY(SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEOFOPERATOR /.Ccs /J✓ �I� ADDRESS NEAREST CROSS STREET PARCEL#(OP11ONAU CIN NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE r� CA 95.3 7,0y,r ✓ Box TO INDICATE D CORPORATION 11 INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY COUNTY AGENCY DISTRICTS D STATE-AGENCY Q FEDERAL AGENCY TYPE OF allSINESS Q t GAS STATION Q 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#Iopumal) Q 3 FARM Q 4 PROCESSOR a RESERVATION O 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) ✓ 1v� 2dLic% 2_ ''-"F- 73Jt NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WIIH AREA COOP Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box biMkate Q INDIVIDUAL EDLOCAL-AGENCY CORPORATION � PARTNERSHIP STATEA-AGEN GENCy CITY NAME OCOUNTY-AGENCY Q FEDERAL-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boYb11131taN Q INDIVIDUAL Q LOCAL-AGENCY � STATEAGENCY CITY NAME O CORPORATION PARTNERSHIP COUNTYJGENCY Q FEDERAL-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE IV.TY BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HO F474-1- 0 3 d a Co� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bll{bdN O 1 SELF-INSURED 0 2 GUIRANTEE �3 MSURANCE D 5 LETTER OF CREDIT 0 6 EXEMPTION O a SURETY SONO Q 59 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boX or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Ee� it. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR WTED E SIGNATURE) APPLICANTS TIRE DATE MONTWDAYf/EAR LOCAL AGENCY USE ONLY CO�UNTYY# JURISDICTION# FACILITY# =`� Y R LOCATION COD OPTIONAL (CENSUS TRACT# -OPTIONAL BUPVISOR-DISTRICT CODE -OPT)ONAG �� Z3 pp 3�4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A("I) • �� FORON3A-5