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STATEOFCAUFORMA .� "� STATE WATER RESOURCES CONTROL BOARD 3 a / UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE `a�.csM�' MARK ONLY E] EW PERMIT ❑ 3 RENEWAL PERMIT [25 CHANGE OF INFORMATION PERMANENT CLOSED SITE ONE REM ❑ 2 iiTrRIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITYYNNgME \\ NAME OF OPERATOR 1—Y'JC- \Tem ADDRESS NEAREST CROSS STREET PARCELO(OPTIONAU CITY NAMS, �` ST TE ZIP 5-0,10SITE PHONE*WITH AREA CODE CA eC ]`�V �� TOIN Box I1 CORPOR TION Q INDIVIDUAL PARTNERSHIP 2 Iw^L-AGENCY �roumm GENCY' O STATEAGENCY' O FEDERALAGENCY' DISTRICTS' 'N owner of UST Is a public agency,mrnplev,the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS ❑ 1 GA STATION ❑ 2 DISTRIBUTOR ❑ flESEfl INDDIAN *OF TANKS AT SITE E.P.A. I.D.*japtino Q 3 FA M d PROCESSOR 5 OTHER OR TRUST LANDS EMERGENC Y CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NA CARE OF ADDRESS INFORMATION 1 MAILING 04STREET ADD RE ( ✓b%bkdkab E:l INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY ED CORPORATION [::] PARTNERSHIP Q COUNfYAGENCY 0 FEDERAL-AGENCY CITY NA E Gt n STAT$�q ZIP CODE � PHONE*WITH AREA-5 7 DE III. TANK OWNER INFO MATION-(MUST BE COMPLETED) l/ J OU NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL O LOCAL AGENCY Q STATE-AGENCY O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- V. PETROLEUM UST FI ANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓hox bNMkate 11 1SELF-INSURED O 2 GUARANTEE O S INSURANCE O4 SURETYBOND 1-15 LET-EROFCREDIT 6 EXEMPTION ] 99 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 OFMY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHrDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# - 3 1zJ v 10 LOCATION CODE -OPT/ONt)� CENSUS TRACT# OPTIONAL SUPR-DISTRICT CODE -OPTVAML THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF%SITE INFFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3193) • . Fr'" r