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STATEOFCALIFJRISA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A �a, a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O t NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM Q 2 INTERIM PERMIT 0 a AMENDED PERMIT Q e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME NAME OF OPERATOR ADD /yam, ., NEAREST CROSS STREET PARCEL#(OPTONAL) z 1 . b V7 _)f, �I CITY NAMEi STA ZIP CODE SITE PHONE#WITH AREA CODE ,! CA TOINDIICATE �CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Cl COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL AGENCY' DISTRICTS' N owner 1N UST Is a public agency,comlete the following:name of Supervisor of division,section,or office which orates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESERVATION ✓ IF INDIAN #OF TAN SITE E.P.A. I.D.#(optimal) 3 FARM 4 PROCESSOR � 5 OTHER 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) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CAREOFADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box blisgaN INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY C--)CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY FEDERALAGENCY CITY NAME 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 b irsicale Q INDIVIDUAL Q LOCAL-AGENCY O STATE AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY O 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 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ how blMkate 1 SELF-INSURED L7 2 GUARANTEE 1E 3 INSURAUR NCE O A SETYBDND 5 LETTEROFCREDT O 6 EXEMPTION 99 OTHER i VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles{s box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. XL` IL 0 IIL� 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) OWNEWSTITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# -OSf153 u LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 9UPVISOR-DISTRICT CODE -OPT10AML 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 lyeG) FORON3AR7 a 0