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ebouacea STATE OF CALIFORNIA � °o STATE WATER RESOURCES CONTROL BOARD `S .o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY E] I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR _ e-,- f�4_ G4 i.,o e-77z- �V c.. _ ADDRESS x 30 NEAREST CROSS STREET PARCEL 0(OPTIONAL) ��. , M CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA Z-0p- YB�2BOX —8rt TOINDIC TE. O GOB RATION INDIVIDUAL E-1 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE-AGENCY DISTRICTS D FEDERAL-AGENCY TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ '/ IF INDIAN #OF TANKS AT SITE E. PESE RVATION ❑ 3 FARM ❑ d PROCESSOR Lpll OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: ME(LAST.FIRST) NIGHTS: NAME(LAST,FIRSn / 4 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) pwnmp 4 WITH AREA GO II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION xwme a 3' 7-- MAILING MAILING OR STREETADDRESS ✓pox o Indicab Q INDIVIDUAL O LOCAL AGENCY STATE-AGENCY (]CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING O SSTREET ADDRESS ✓ tar biMkau INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP L-1 COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4 1I4] - V. PETROLEUM UST FINANC L RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ pox to inNcale r jI SELF-INSURED [__1 2 GUARANTEE 0 3 INSURANCE Q d SURETY BOND IJ 5 LETTER OF CREDIT [:::]6 EXEMPTION 0 0 OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless checked. / CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EKII.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR ( LOCAL AGENCY USE ONLY COUNTY# JURISDICTION FACILITY# Flca-e �3� LOCATION CODE -0�NAL (CENSUS TRACT# OR LQNAL SUPVISOR-DISTRICT CODE -OPPTIO AL 3 THIS FORM MUST SE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORM TION C FORM A(12 eu FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS