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STATE OF CAUFORNIA :! :o STATE WATER RESOURCES CONTROL BOARD .e n UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A :! , o COMPLETE THIS FORM FOR EACHFAC11TYISITE `�lpOa"�' MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONIx 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 0 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR rA 0 '1 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 63 a i CITY NAME ' I V v STACA ZIP CODE a 5 SITE PHONE WITH AREA CODE 7_5 TO INDICATE CORPORATION INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' DISTRICTS' If owner G UST is a public agency,coWlete the following:name of Supervisor of dWbbn,section,Or office which operates the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR E__1 ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(optional) RESERVATION 3 FARM ❑ 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(UST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHWITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bmbNMkate [::] INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxisinEam [�D INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY D CORPORATION = PARTNERSHIP O COUNTY-AGENCY Q FEDEINLAGENCY 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) HQ F4-W- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bla bYMkate O t SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 5 LETTEROFCREOIT =6 EXEMPTION E:j 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. CHECKONE 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 OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# i'FACILITY It m LOCATION Q -OPTIONAL CENSUS RA -O;TTL SUPVISOR-DISTRI:TCODE -T#PTADNAL 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(393) FOR0033AA7 F4K P r�N�•- 0