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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w� _ COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSUR I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF ILITY NAME NAME OF OPERATOR V', G ADDRESS_ /� NEAREST CROSS STREET PARCEL#(OPTIONAL) 1 J\ t CITU NAMESTATE ZIP CODE75 SITE PHONE S WITH AREA CODE I/ e TO INDICATE CA CATE D CORPOMTONNDIVIDUAI (]PARTNERSHIPI� DISTRICTS'LOCAL-AGENCY FUMY-AGENCY' (]STATE-AGENCY• O FEDEIIAL#GENCV' S owner of UST Is a public agency,corrplet he foilowing:name of Supervisor of division.section,or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.a isl ipml) ❑ 3 FARM ❑ 4 PROCESSOfl 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAY$; NAME(LAST.FIRS HONNEE x WIT ABFA-.CO E_O DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FAST) OZONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWININ INFORMATION- MUST BE COMPLETED NAME CAREOFADDRESS INFORMA N MAILING OR STREET ADDRESS ✓ boxbindkals = INDIVIDUAbN O LOCAL AGENCY f=STATE-AGENCY CORPORATION 0 PARTNERSHI COUNTY-AGENCY =FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-*ST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa to indicate L-1 INDIVIDUAL LOCAL. FNCY (]STATE-AGENCY CORPORATION O PARTNERSHIP Q COUNTYA NCY E::] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE 0 H AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE AC%UNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MCOMPLETED)—IDENTIFY THE METHOD(S) USED ✓box IDindicals O t SELF-INSURED 2 GUARANTEE O 3 INSURANCE 0 4 flETY BOND f�5 LETTEROFCREMT EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification*d 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 NOTIFICA NS AND BILLING: I.❑ I.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOT BEST CF MY KNOWLEDGE,IS TRUEAND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If FACILITY 0 3:1 LOCATION CODE -OPTIONAL CENSISTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �N3 OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS N b FORM A(3413) FONaa33,lAT 1