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�� • ftyOUw f9 STATE OFCAOFOfWIA `` .° •. `i. STATE WATER RESOURCES CONTRk BOAR; ; UNDERGROUND STORAGE TANK PERMIT APPLICAVION - FORM A m � Nv COMPLETE THIS FORM FOR EACH F CILITYISITE "��"°"�•" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �( I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAM NAME OF OPERATOR 0 Salc> i)� 10%)Ar .4 ADDRESS 1 NEAREST CROSS STREET PARCELa IOPrIONAU 3$70F-c- CITY NAME STATE ZIP CODE SITE PHONE k WITH AREA CODE C� CA 930 I/ Box TO INDICATE D CORPORATION D INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY I] STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR I = ✓ INDIAN *OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION ❑ 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(( AST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME v sc- CARE OF ADDRESS INFORMATION w/G 5 MAILING OR STREET ADDRESS I ✓ boxbinCkale 0 INDIVIDUAL ELI LOCAL AGENCY L�STATE-AGENCY J Z.0 O CORPORATION Q PARTNERSHIP 0 COUNTY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE C'4 ys 33� III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS• ✓ box 0 Micate 0 INDIVIDUAL O LOCAL AGENCY (]STATE-AGENCY O CORPORATION L_j PARTNERSHIP I=COUNTY AGENCY FEDERAL-AGENCY CITY NAME' STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14 4 n 5 2 2 2 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindkale I SELF INSURED I] 2 GUARANTEE L] 3 INSURANCE 7]4 SURETY BOND 5 LETrEROFCREDIT 6 EXEMPTION 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 APPLICANTS NAME(PRINTEDA SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY t COUNTY# JURISDICTION It FACILITY# TFF6U. /Z LOCATION CODE OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ^�✓/ 2 -3-14f—e/3 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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS y FOR0033A R6