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• • STATE OF CALIFORNIA / STATE WATER RESOURCES CONTROL BOARD' o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRY/SITE °�1�•°��,• MARK ONLY ❑ 3 NEW PERMIT ❑ 7 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 2 DBAOR FACILITY NAME ` NAME OF OPPEE�RATOR 1 Cf ADDRESS NEARESTCRO5S_ REET PARCELA(OPTpNAL) CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE A �� CA S ZPJZ TO INDICATE D CORPORATION D INDIVIDUAL O PARTNERSHIP OCALAGENCY O COUNTY.3GENCY 0 STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ ( GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.A(opTNne/) 3 FARM 4 PROCESSOR 6 OTHER RESERVATION / ❑ OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREACODE NIGHTS: NAME(LAST,FIRST) PHnNP I WITH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME C N (` S CARE OF ADDRESS INFORMATION MAILING OR STREET AD ESS ✓ OmbiMkm (:D INDIVIDUAL 0 LOCAL-AGENCY 0 5TATE-AGENCY Ll-L S CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE Se �s�� CST 1 95 7-C->-Z-- zCIF z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Q^R MG as MAILINGoA STREET ADDRESS- ✓ boz DiNicM Q INDIVIDUAL Q LOCAL-AGENCY STATE AGENCY O CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME' - STATE ZIP CODE PHONE R WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HO V. PETROLEUM UST FINANCIAL RESPONSIBILITY• (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED y ✓ Eaz mi�gkab I SELF-INSURED L__j 2 GUARANTEE Q 3INSURANCE A SURETY SND 9! I= 5 LETrEROFCREDIT = 6 EXEMPTION 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. pp CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ J.� III.❑ II THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT 1 APPLICANTS NAME(PRINTED851GNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY xJURISDICTION# - LOCATIONCODE OPTIONAL ICENSUSTRACT:1 -OPTIONAL ISUPVISOR-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. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 FORD033A.R6