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�eWn f STATE OF CALIFORNIA Af. STATE WATER RESOURCES CONTROL BOARD i �0 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e� COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ONE REM 2 INTERIM PERMIT O a AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ORA OR FACILITY NAME NAME O��R ADDRESS S NEAREST CROSS STREET PARCELa(OPTIONAL) 4 t CITY E ST TE ZIPP CODE SITEPHONEi WITHAREACODE ✓ qL Boz ~ �✓ TOINDICATE CORPORATION =INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY I-D COUNTY-AGENCY' O STATE AGENCY' D FEDERAL#GENCYIST ' If owner M UST is a public agency,complete the following:name of Supervisor of division.section,or ofCco7SWhbh operates the UST TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTORTH ✓ #IF INDIAN OF TANKS AT SITE E.P.A. I.D.#(ptavonal) 0 3 FARM O A PROCESSOR 5 OER O RESERVATION OR RUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional DA S: NAME(LAST.FIRIM PHONE#WITH AREA CODE DAY ' NAME(LAST,F n PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME((JST,FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAM CARE OF ADDRESS INFORMATION MAILING OR STREET DRESS ✓ box bindkab INDIVIDUAL 0 LOCAL AGENCY [_3STATE.AGENCY O CORPORATION PARTNERSHIP D COUNTY AGENCY O FEDERAL AGENCY CITY NAME STATEZIP CODE PHONE i WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate E�l INDIVIDUAL 0 LOCAL AGENCY l= STATE-AGENCY O CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY = FEDERALAGENCYCITY 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) HQ 4 j4d- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to Indicate 0 1 SELF INSURED 0 2 GUARANTEE E:]3 INSURANCE O 5 LETTEROFCREOIT a SURETY BOND 6 EXEMPTION � W 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.[—] 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 B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY it 9A] ® � LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(393) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN STORAGE TANK REGULATIONS /�.-. 41/1 -1 '� FOR0003A117