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f STATEOFCALIFORNIA o �✓ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY MARK ONLY ONE REM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) f 6, NAME OF OPERATOR nPA 09 FACILITY NPME - NEAREST CROSS STREET PARCEL/(OPTIONAL) ADDRESS 00 G CITY NAME, STATE ZIP DE SITE PHONES WITH AREA CODE D G CA Jt ✓ Bo% F7 CORPORATION Q INDIVIDUAL O SM PARTNERP Q LOCAL-AGENCY Q COUNTY-AGENCY' C STATE-AGENCY' O FEDERAL-AGENCY' T01NOICATE DISTRICTS'. If owner of UST Is a Public agency,mn-ciete the follmmg:name of Supervisor of ENlsion,ae°ibn.or office which operates the UST TYPE OF BUSINESS i GAS STATION 2 DISTRIBUTOR R$EF INDDIAN s OF TANKS AT SITE E.P.A. I.D.s(afxlonap 3 FARM ❑ A PROCESSOR 5 OTHER OR TRUST LANDS 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional OAYKAME(LAST,FIRSn, PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE K IY PHONE s WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST.FIRST) It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CAPE OF ADDRESS INFORMATION NAME pinif I(- fi u Ye ✓) G MAILING OR STREET ADD ESS ✓ SOAbmENau '✓ INOIVDUAL _ LOCAL-AGENCY iJ STATEAGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEOERAL-AGENCY CITY NAME ( STATE ZIP CODE PHONE S WITH AREA CODE I III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION YLI YY� QAC MAILING OR STREETADDRESSPlf I ✓ SOA oiMirau '� INDIVIDUAL C LOCAL-AGENCY L; STATE-AGENCY L.�CORPORATION PARTNERSHIP J COUNTY AGENCY I,J FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HO 4 4- -I� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ 5W biMkate O I SELF411SURED =2 GUARANTEE 3 INSURANCE A SURETY BOND O 5 LETTEROFCREDIT I=6 EXEMPTION Q N 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.g I.❑ 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 6 SIGNED) OWNER'S TITLE DATE MONTHNAY/YEAfl ffLOMCATION GENCY USE ONLY T I� COUNTYa JURISDICTION a DE -OPTIONAL (CENSUS TRACT( -Q°TIONAL i.UPVISOR-DISTRICT -OPTA7 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 UNDERGROU D STORAGE TANK REGULATIONS j v' I� FoRomAT FORM A(3AT3) - k L, " G� y -