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• • Esc ^ e STATE OF CADFORMA ,° STATE WATER RESOURCES CONTROL BOARD W��r a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , os J COMPLETE THIS FORM FOR EACH FACILTTYISITIE � °n,rua+'- MARKONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR J � � I ADDRE SaNEAR ST CROSSSTREET PAR (OPTIONAL) . , s Wd� CELN CITY NAME /��D / ST TE ZIP E SITE PHONE a WITH AREA CODE TO BOX {/ –hiAAALCCORRPORATION 0 INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY• [_1 STATE-AGENCY, E:1 FEDERAL-AGENCY' •H owner d UST is a public agency. DSTRICTS' P e cl'•mmplele the following:name of Supervkor d oNisbn,seclbIn or office Whbh oparatec the UST TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR / IF INDIAN a OF TANKS AT SITE E.RESERVATION P.A. I.D.R(optional) 3 FARM 4 PROCESSOR X 5 OTHER OR TRUST LANDS ,�— EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE D11t I o 541-�f7a E NIGHTS: N (LAS ST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST, FIST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME / D CARE OF ADDRESS INFORMATION MAILING��O••R��S(T�R✓EET ADDRESS] �,Hy-- /��, _/ l✓`Eo[bindkab INDIVIDUAL I� L -A EN* Q STATE-AGENCY 3 ✓ a 14a /I l� 13 1 Ild, Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CI1V N ME STATE ZIP CODE PHONE a WITH AREA CODE Ge. III. TANK OWNER INFORMATION-(MUST BE COMPLETED) IF—: ?(Jr 6/f NAME OF OWNEeR^h n CARE OF ADDRESS INFORMATION MAILING OR STREET ADDR v ✓ boa bintlbae Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY Q CORPORATION O PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY 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 44- -L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ boa birAkats Q I SELF INSURED 0 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND 0 5 LETTEROFCREDIT Q 6 EXEMPTION Q IS OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[Ij II.❑ 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&SIGNED) OWNEWS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY ` COUNTYII JURISDICTION p FACILD-Y4-- LOCATION CODE -OPT® CENSUS TRACTa -OPTIONAL 9UPVISOR-DISTRIC -f3P - 0 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK= FORMAP" � '19POR0077AJ17