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•s Vo e STATE OF CAUFOHWA :�' ti STATE WATER RESOURCES CONTROL BOARD W., - n a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ,, COMPLETE THIS FORM FOR EACH FACILITYISITE ��lpUn"" MARK ONLY O I NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY SIT ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /OI DBA OR FACILI NAME /� NAME OF OPE I RI b - ADORES �- ` NEAREST CROSS STREET V PARCEL`#(OPPTTIIOCNAAL) V CITU NAME STATE ZIP CODE I SI PHONE s W ,A 1^ 7 10 NgoxTE =1 CORPORATION INDIVIDUAL �PARTNERSHIP l� LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' l� FEDERAL-AGENCY' DISTRICTS' 'I owner G UST is a public agency,consists the lo2owing:name of Supervisor of division,section,or oaks which operates the UST TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN ,OF TANKS AT SITE E.P.A. I.D.,(apl/av/) RESERVATION 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS L?MERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE,WITH AREA CODE DAVE: NAME(LAST,FIRST) PHONE,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 NAMECARE OF ADDRESS INFORMATION �0 es MAILING OR STREET ADDRESS ✓ buloIndbate E:3 INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAMEST TE ZIP ODE PWONE i WITH AREA CODE T--C.., Oma/' 7 17 ff III. TANK OWNER INFORMATION-(MUST BE COMPLETED) A NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY D CORPORATION PARTNERSHIP O COUNTY-AGENCY D 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 M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicate O I SELF INSURED O 2 GUARANTEE I] 3INSURANCE O 1 SU TY BOND D 5 LETTEROFCREDIT O 6 EXEMPTION OTHER y 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 OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION N ,FACILf Y11-1 66F LDCATION DE -OPTIONAL CENSUS TRACT, -OPTIONAL SUPVISOR-DSTRxOT CODE -OPTIONAL D 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 FORM A(393) �j,F,OR003 AR7 t /� P 4.