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�' 'l • STATE OF CAUFORWA • la STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION•FORMCOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PER ENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEARE TCROSS STREET PARCEL 0(OPTIONAL) CITY NAME STA ZIP C23,— -7; SITE PHONEY WITH AREACODE G,4 A TOIN BOX O CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENDY' DSTRICTS' If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or onlce which operates the UST TYPEOFBUSINESS ❑ 1 GASSTATION ❑ 2 DISTRIBUTOR / ✓ IF INDIAN NOF TANKS AT SITE I E.P.A. I.D.#(apfanep N+ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR d OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 5 Gc� 1 t 412116 NIGHTS: NAME(LAST,FIR PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE O Z,15-6- 'T16 -4a o ; If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME ,xG / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDR S / ✓bmbindkale O INDIVIDUAL LOCAL-AGENCY STATE-AGENCY / }�j�¢(Q CQQ� =CORPORATION = PARTNERSHIP 0 ODUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE r- � 9533-7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blrdkm 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION 0 PARTNERSHIP COUNrY AGENCY I] FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)3229669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boxblrbkaU O 1 SELF-INSURED L_j 2 GUARANTEE L_j 3 INSURANCE 0 4 SURETY BOND D 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 cp6ed. CHECKONE 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 OWNERS NAME(PRINTED S SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY 3 COUNTY# JURISDICTION# PACILTITW_ ;; P 97 1 LOCATION CODE -OPTION 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. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3'93) FORONSAAT