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0 'eyo�n e c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �� to UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH F RY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) J DBA OR FACILITY NAME // NAME OF OPERATOR ADDRESS NEAR ST CROSS STREET PARCEL#(OPTIONAL) Ga C4 re / CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S cu��in CA ✓ Box TO INDICATE D CORPORATION 0 INDIVIDUAL PARTNERSHIP 0 LOCALAGENCY COUNTY-AGENCY (] STATE-AGENCY O FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION / ❑ 3 FARM ] 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional FNIGHTS: ST,FIRST) -. PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) son -9YC/ fa7 LAST.FIRST) P #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME 5 CARE OF ADDRESS INFORMATION MAILING OR STREET AIDDRESS ✓ boxbI I;ale = INDIVIDUAL ED LOCAL-AGENCY STATE AGENCY N a 4 cQ J 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREETADDRESS ✓box to Indicate INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL AGENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ F41 4 - 6 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ WXbindRale O 1 SELF-INSURED I]2 GUARANTEE CD 3 INSURANCE 111 5 LETrEROFCREDIT (]6 EXEMPTION D 4 SURETY BOND I�as OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch 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 TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# bj6(N as LOCATION CODE -OPTIONAL CENSUS TR T# -QPTIONAL SUPVISOR-DISTflICT CODE -OPT/ONAL J,�-(j a '3 c-0 ,(1v/S FORTHIISSFORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE IN NATION ONLY. �G/ if 000 (/%//// 11