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• • 160V- ! STATE OF CALIFORNIA �� ''� STATE WATER RESOURCES CONTROL BOARD + ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� i , o COMPLETE THIS FORM FOR EACH FACILITYISITE � °�c,.clo�- MARK ONLY D 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED BITE ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DRA OR FACILITY NP.ME T NAME OF OPERATOR .b1 Al e: 4- _J/�/ TAA ADDRESS NEAREST CR09 STREET PARCEl(OPTIONAL) >G `. >" T 12— CITY ZCITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE CA ✓ BOX — TOINDICATE ED CORPORATION [__1 INDIVIDUAL E-1 PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' DISTRICTS' If owner of UST Is a public agency,co plate the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS O t GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF!TANKS AT SITE E.P.A. I.D.*(optional) O RESERVATION ® 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindban 11 INDIVIDUAL Q LOCAL-AGENCY [fj STATE-AGENCY p_ CORPORATION 0 PARTNERSHIP COUNTY AGENCY =1 FEDERAL-AGENCY CITY NAME STATF� ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ESfT�, T2i MAILING OR STREET ADDRESS e ✓ box bIndicate INDIVIDUAL LOCAL AGENCY O STATE AGENCY E. 7; ' ,eT. /Z CORPORATION 0 PARTNERSHIP Q COUNTY AGENCY O FEDERAL AGENCY CITU 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 b Indicate Q I SELF INSURED O 2 GUARANTEE l71 3 INSURANCE 4 SURETY BOND 5 LETTEROFCREDIT O 6 EXEMPTION O Is 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: L IL 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 A SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# - - LE Em LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OILY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOSTORAGE TANK REGULATIONS FORM A(393) • is Fp10W3AA7