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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD "eg AA, �� �� UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ' , , s COMPLETE THIS FORM FOR EACH FACILITY/SITE `'x�^�^"�� MARK ONLY ❑ t NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 7 + E ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME A /I'. i.A NAME OF OPERATOR ' (Gl?.LG(iYN ADDRESS NEAREST CROSS STREET PARCEL/(OPTIONAL) Y CITU NA STATE ZIP OOE SITE PHONE#WITH AREA CODE CA TOINpCATE CORPORATION (]INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY CWNTY AGENCY' O STATE-AGENCY' EDFEDERAL-AGENCY' DISTRICTS' , ` 'If Amer d UST la a public agency,mrtplde the following:name of Supervisor of division,section,or office which operalec the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR gESERVAOTION IANI#OF TANKS AT SITE E.P.A. 1.D.#(gnfiorraQ O 3 FARM Q 4 PROCESSOR 5 OTHER Oq TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME LAST,FI ST) PHO #WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE �] NIGHTS: NAME(LAST.FIRST) PHO N WITH AREA CODE NIGHTS: NAME(L 1,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER I ORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMA ON MAILING OR STREET ADDRESS box bindbaN O IND IVID L E:3 LOCAL-AGENCY O STATE-AGENCY 0 CORPORATION O PMTI! IP Q roux TYAGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•( ST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bbdbate Ij INDIVIDUAL El N OCAL-AGENCY D STATE-AGENCY O CORPORATION O PARTNERSHIP Q LINTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE I PITE#WITH AREA LADE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions aris TY(TK) HQ M44- V. 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bimicate L SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE L—j 4 SURETY BOND 5 LETTER OF CREW O 6 EXEMPTION O Pg 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. If. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'SNAME(PRINTEO S SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY C�OUNpTY�# JURISDICTION At FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP a THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS T48 IS ACHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033Mi7 FORM A(393) I%'.. /�—/�✓��