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STATE OF CALIFORNIA J, STATE WATER RESOURCES CONTROL BOARD c UNDERG ND STORAGE TANK PERMIT APPLIC N • FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE 'a•t„a,,,;-' MARK ONLY ❑ I NEW PERMIT ❑ 3 FENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMAN ED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ s AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA R,�ACILI yM1E NAME OF OPE TOA /` I I. ADORES NEARESY CROSS STREET f fPARCEL#(OPTIONAU C CITY NA,VF. STATEZIP COO -3 SITE PHON #W TTH AE RFA CODE CA CC // TO IN(LATE O CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCALAGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL AGENCY' DISTRICTS' n owner of UST Is a public agency,comlete the to6owing:name of Supervisar of bivuon,section,or a#ke which operates the UST TYPE OF BUSINESS Q T GAS STATION a 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE RESERVATION Q 3 FARM Q a PROCESSOR 5 OTHER OR TRUST CMOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional GAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITI:AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME - CAgE OF ADDRESS INFORMATION MAI IN O TREET- DORES5 ✓ Dos biNkals INDIVIDUAL� O � LOCAL-AGENCY Q STATE-AGENCY �(J d Q CORPORATION FPARTNERSHIP ED COUNTY-AGENCY Q FEDERAL-AGENCY CITY AWe, STAT L ZIP - PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CC L Nc OF OWWR A ` CARE OF ADDRESS INFORMATION r/ AILING OR STRE``FYADO/R�ESS D J boa nwkme Q INDIVIDUAL O LOCAL AGENOY ED STATE-AGENCY CORPORATION ARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP C PHONE#WITH AREA CODE S33G2 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 BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ion bindicate Il I SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE O r SURETY BOND CD 5 LETTEROFCRECIT (]6 EXEMPTION Q W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank ownerunless x I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT OWNERS NAME(PRINTEO&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m 1 LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY 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(3931 FCRxa11a7