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STATE OF CAUFORtaA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F--j 1 NEW PERMIT O 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSE TE ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE �a I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU CITY NAME STATE ZIP CODE ITE PHO pE E#)Np A //i_T� CAZ� 'S3� TO INDICATE ATE ED CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' DISTRICTS' N owner of UST Is a public agency,ocnplela the following:name of Supervbor of division.section,w office which operates the UST TYPE OF BUSINESS f GAS STATION Q 2 DISTRIBUTOR / IF INDDIAN N OF TANKS AT SITE E.P.A. I.D.#(oplAansg Q 3 FARM 4 PROCESSOR 6 OTHER I OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE / - , NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS I ✓ lex biMbaN OINDIVIOUAL Q LOCAL-AGENCY STATE-AGENCY =CORPORATION =PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE 27 1P COsE PHONE#WITH AREA CODE �} /v III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESSrr ✓ boxbind'bme INDIVIDUAL LOCAL-AGENCYOSTATE-AGENCY 4- n '=j�/ r�"�'�� I�CORPORATION PARTNERSHIP COUNTY-AGENCY L:J FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#l WITH A44EA CgD�(l. >Z�/v � ED IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box tolnebab E-1 t SELF INSURED 2 GUARANTEE O 3 INSURANCE E-1 4 SURETY BOND O s tETTEROFCREOT D 6 EXEMPTION 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: I.O if.D 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'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY If JURISDICTION# FACILITY* m r 1!5K> LOCATION CODE -OPTIONAL CENSUS TR_ACT0 -OIPTIONAL SUPVISOR.DISTRICT CODE -OWTIOAW i/ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 191 to FORa073Afl7