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STATJOFCAUFORWA ,� ''� STATE WATER RESOURCES"CONTROL BOARD `„ :o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE °�x�.o-+" MARK ONLY ❑ t NEW PERMIT 0 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 6/ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR F4.QILITY NAME 11 NAME OF OPERATOR C,KXI 9T ADDRESS NEAREST CROSS STREET PARCEL 9(OPTIONAL) 2sos� tial-�,� CITY NAME ije � STATE ZIP CODE SITE PHONE a WITH AREA CODE t.t. . cA 9 z36 TOINDCATE O CORPORATION D INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' D FEDERAL-AGENCY' DISTRICTS' 9 inner f UST Is a public agency,oom(Aete the following:name W Supervisor of dNBbn,section,or office which operates the UST TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTORQ ✓ IFINDIAN #OFTANKSATSITE E.P.A. I.D.a(opt/onaq RESERVATION / FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION )e1*1,x?CP5 MAILING OR STREET AD ZIESS ✓ box birdlale INDIVIDUAL O LOCAL-AGENCY OSTATE-AGENCY Q 17 3 O CORPORATION D PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE C/CAyrell 75 e* 7--7-7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bhbbate 0INDIVIDUAL ED LOCAL-AGENCY STATE-AGENCY O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D FEDERAPAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bin&ate O t SELF-INSURED 2 GUARANTEE 3 INSURANCE s SURETY BOND O 5 LETTEROFCREDIT O s EXEMPTION a 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unleskbox I or II i hacked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Ft II.56 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNEWS NAME(PAINTED&SIGNED) OWNER'S TITLE DATE MONTH)DAYNEAR LOCAL AGENCY USE ONLY V, '60.5-Y 7C1 FID aD • COUNTY# JURISDICTION# FACILITY• - aS 3 LOCATION CODE -OPTIONAL CENSUS TRACT-OPTIONAL SLNWISOR-DISTRICT OODE -OIPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) (� FOg9033A.R7 l)