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♦te �a STATE OF CALIFORNIA .� STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A n� COMPLETE THIS FORM FOR EACH FACILITYISITE `�t�.an+" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE 'j v I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ACILI NAME NAME OF OPERATOR ADORr i") NEAREST CROSS STREET PARCEL#(OPTIONAq E�S v I> nw2L CITY ( STATE ZIP CODE SITE PHONE WITH AREA CODE 1(l��CtG CA ✓ BOX TOINDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY' D FEDERAL-AGENCY' OBTPo 'If owner d UST Is a public agency,mnplete the following:name of Supervisor of dNkbn,section,or officer which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTORT- - qV IF INDOAN a N# OF TANKS AT SITE E.P.A. 1.0.#(ppllanal) ❑ 3 FARM ❑ 4 PROCESSOR E�-;�6 OTHER OR TRUST LANDS ��-- EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE �7] NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE ll, PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME -^ _ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bwbhb'bab O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOF OWNER j CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS- T vlAl�J ✓ bot b indicate L__1 INDIVIDUAL O LOCAL AGENCY ED STATE-AGENCY O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 it questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIntlkate 0 I SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION 0 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: 1.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY* m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)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 FORM A(393) FORDMIA-117