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• • -U60U9 f C STATE OF CAUFORWA STATE WATER RESOURCES CONTROL BOARD i '4 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 5r COMPLETE THIS FORM FOR EACH FACILITY/STTE �.�,.o,..�•-e MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED nS ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT NEjj�—S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR r ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) rr�o��a o v � CITY AME STATE ZIP CODE ITE PH E#WITH AREA CODE �p CAv BOX TO INDICATE CORPORATION IDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY AGENCY• DISTRICTS' STATE-AGENCY' D FEDEPAL#GENCY' If avnor d UST la a public agency,complete the following:name of Supervisor of dNlsbn,,action,or office which operales the UST TYPE OF BUSINESS ❑ , GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.0.#toplional) RESERVATION 3 FARM O 4 PROCESSOR 5 OTHER OR RESERVTRUSTANOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Qli�ie4 d -� NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME( FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS > ✓ boxblMkale INDIVIDUAL LOCALAGENCV IEj STATE-AGENCY Ij CORPORATION = PARTNERSHIP 1:1 COUNTY AGENCY = FEDERALAGENCYCITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAIL( GOR STREET ADDRESS ✓ mxbimrale INDIVIDUAL = LOCALAGENCY -STATE AGENCY CORPORATION O PARTNERSHIP = COUNTY AGENCY Q FEDERAL-AGENCY CITY ry/AME STA ZIP CO PHONE# ITH AREA CODE - 58 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bindbzte 0 I SELF INSURED [-12 GUARANTEE O A INSURANCE 0 A SURETY BOND 5 LETTEROFCREDIT O 6 E%EMPTION = 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: if. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'SNAME(PRINTED&SIGNED) OWNERSTITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY If 7 ® r�V LOCATION CODEw OPTIONAL, CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -G'TpAW. © , THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 15 A CHANGE OF SITE INFORMATION ONLY. FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS Vbl/li • �I • aAA7