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a STATEOFCALIFORWASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA F ILITYN NAMED OPERATOR o R�Cl1A0_0 - ADDRESS • , _ I NE EST ROSS TREET PAgCELR(OPfpNAL) CITY NA �rI '/—NI/W' STATE ZI COE C4� CA _ SITE PHONE#WITH AREA CODE I/ BOX Ott O00"' "' TO INDICATE D CORPORATION (]INDIVIDUAL PARTNERSHIP LOCAL-AGENCY I�fAUIR -AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' If owner of UST Is a public agency,complete the followin :name of Su DISTRICTS g pervlsor of oNis' 6aCibn,or office whkh operates the UST TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTORO ✓ IF INDIAN #OF TAN AT SITE E.P.A. L D.#/gofronal/ 3 FARM = 4 PROCESSOR 5 OTHER RESERVATION OR TRUST LANDS 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 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION MAILING ORSTREETADDRESS ✓ Wx Isindbale 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY CITY NAME CORPORATION L-1PARTNERSHIP 0 COUNTY-AGENCY FEDERAL AGENCY STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blMicale O INDIVIDUAL LOCAL-AGENCY [—I STATE AGENCY CITU NAME D CORPORATION = PARTNERSHIP Q COUNTY AGENCY E:1 FEDERAL AGENCY 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) Hp 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓ box blMkale = I SELF INSURED � UARANTEE 31NSURANCE O 5 LETTER OF CREDIT 6 EXEMPTION O 99 OTHER d SURE BONG 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: 1.0 Il.[�] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME IPRINTED&SIGNED) OWNER'S TRIE DATE MONTWDAV/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m PP- 12KFQMF 3 LOCATION CODE -GIFT, NAL CENSUST CT# . T L SUPVISOR-DISTRICT -OPipµy, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLEA THIS IS A CHANGE OF SITE INFORMATION ONLY, FORM A(34113) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR6033A#17