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STATE OFCALIFJRNIA c 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE °"�r�^"'• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE ONE REM ❑ 2 INTERIM PERMIT [:10 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSUR f„J- O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAFACILITY NAME �— NAMEOF/ T dNE O '/ ADDRESS C NE E T CROSS STREET PARCELa(OPTIONAN / J i 011E CITY NAM /^ / D G / STACA ZIP 5 t�1 P Y ! 1 1 C) y TO INDICATE BOX E:3 CORPORATION D INDIVIDUAL 0 PARTNERSHIP E::] LOCAL-AGENCY 0 COUNTY-AGENCY' [�:j STATE-AGENCY' ED FEDERAL-AGEWY' DISTRICTS' If owner of UST Is a public agency,complale the following:name of Supervreor of d"lon,section,or oNloe which21 etas the UST \ TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR l❑ RESERVATION V IF INDIAN s OF TANKS AT SITE E.P.A. I.D.a IM(kmad) ❑ 3 FARM ❑ A PROCESSOR 6 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAM (LAST,FIRST)/D PHONE a ITa�E COJAE��— V� E(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FZT)� ,^A a PHONE a WITH ARE CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME / ) CARE OF ADDRESS INFORMATION MAILI RSTREETADDRESS Lam/ �}{ ^n , ✓eo°bin&an INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITU NAME �0 n / STOf� ZIP�D��O r PHONE a WITH AREA CODE III. TANK OWNER INFORMATION (MUST BE COMPLETED) JY NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxo1micale INDIVIDUAL O LOCAL-AGENCY E-1 STATE-AGENCY D CORPORATION PARTNERSHIP COUNTY-AGENCY 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 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box binRaab L:1 1 SELF INSURED 2 GUARANTEE = S INSURANCE N SURETY BOND O 5 LETTEROFCREDT ]6 EXEMPTION E�j 90 OTHER 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: I.❑ 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 B SIGNED) OWNERS TITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY G a0 COUNTY N JURISDICTION IN FACILITY• LOCATIOy�O -OPTIONAL CENSUByR i - TIONAL SUPVISOR- IQT� -OPTIONAL THIS FORM MUST BE ACCOMPANIED B9 AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,,,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) 0 0 FORB033M77