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GSTAT60FCAUFORMA STATE WATERd RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME/I1 NAME OF OPERATOR ADORES NEAR TCROSS STREET PARCEL 0(OWONAW .(/y 4C-- CITY AME STATE ZIP CODE SITE PHONE a WITH AREA CODE Ca !2,S7:33 0BOX TO INDICATE EmeCIORPORATION O INDIVIDUAL O PARTNERSHIP (] LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' If owner of UST Is a publicagency,complete B DISTRICTS' p m lero the following:name aT Supervisor o1 oNlebn,Section,or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN 14OF TANKS AT SITE E.P.A. I.D.a(ephorr ) RESERVATION 3 FARM ❑ 4 PROCESSOR b OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAS FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE m 2Arp- SSS( -TS6 3T NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I /� -srss / Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME 4/ CARE OF ADDRESS INFORMATION n�i k-u�, _ MAILING OR STREET ADDRESS ✓ 0 INDIVIDUAL O LOCAL-AGENCY I� STATE-AGENCY '/ CORPORATION D PARTNERSHIP COUNrY.AGENCY Q FEDERAL-AGENCY CITY NAME STPPATE�� ZIP CODE F� PHONE a WITH AREA CODE YT' -z-4d`-' Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNEIy, _ CARE OF ADDRESS INFORMATION YY Qi - MAILINGORSTREETADDRESS ✓DoSbbdiCW 0INDIVIDUAL I� LOCAL-AGENCY 0 STATE AGENCY A- O CORPORATION D PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME �. ST^AATE�� ZIP CODE PHONE#WITH AREA CODE N T IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boxbindIcae I�I SELF-INSURED Q 2 GUARANTEE I�s NSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT O B EXEMPTION 1✓wee OTHER Vl. 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: I.❑ II.❑ III! THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT OWNERS NAME(PRINTED B SIGNED) OWNERS TITLE DATE MONTHMAYIYEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# FACILITY• LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL N / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMB,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 , FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS . FgWdDMNT I