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STATEOFCAUFORTSA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY t NEW PERMIT a 3 RENEWAL PERMIT D 5 CHANGE OF INFORMATION V 7 PERMANENTLY CL ED SITE ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAO FAC ITYNAME NAMEOFOPeRATOR ADDRESS / N ESTCSST Y,-./ f)� PARCELIIOPIIONAL) CITU NAME STACA ZIP OpFj��7 ,� SITE PHONE i WITH AREA CODE Box TO INDICATE O CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY E-3 COUNTY AGENCYQ STATE-AGENCY' O FEDERAL-AGENCV' If owner of UST is a public agency,mmylete the following:name of Supervisor of division,sectbn DISTRICTS ar office which operates the UST TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN ISS,AT SITE E.P.A. 1.D.;1(gNronal) 3 FARM q PROCESSOR 5 OTHER RESERVATION OR .Fill TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA COOS NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING ORSTREET ADDRESS /„ /t ✓ box b Indicate 0INDIVIDUAL LOCAL-AGENCY CORPORATION 0 FEDERSTATE AL-AGENCY CITY NAME D PARTNERSHIP �COUMY�AGENCY � FEDERAL-AGENCY STATE ZIP CODE PHONE IF WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ pox birdkale INDIVIDUAL 0 LOCAL AGENCY =1 STATE AGENCY O CORPORATION E-1 PARTNERSHIP Q COUNTY AGENCY FEDERAL AGENCY CITY 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 M44- - 7� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindkale Q 1 SELF-INSURED _ =2 GUARANTEE =3 INSURANCE 0 4 SURETY SONO ED 5 LETTER OF CREDIT =6 EXEMPTION 0 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.E III.L3 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MIXNTWDAY/VEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# -44- LOCATIONCODE -OPTIONAL CENSUS TRAC i -OPT/ lJ✓✓�L 9UPVISOR-DIST T -WTp THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,lnim LE S THS A CHANGE OF SITE INFOpNATK)N ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI" FORMA(393) . ) FOR0033AA7