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STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A . COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION O 7 PERMANUaLV-CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) r)PA OR FACILITY NPM • I NAME OF OPERATOR !J F ADDRESS NEAREST CROSS STREET PARCEL # (OPTnNAL) l� CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA GOE E � v Box CA TOINDICATE O CORPORATIONINDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY AGENCY Q STATE AGENCY ' Q FEDERALAGGEENCY ' DISTRICTS' - It owner of UST is a public agency, complete the following: name of Supervisor of tlMsicn, Section, or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / ❑ RESERVATION VIF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (eplicna)) 3 FARM ❑ 4 PROCESSOR ,LYY.-J/5 OTHER OR TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optlonal DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE k WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION • MUST BE COMPLETED NAME e& ,A 7 CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box biMkate O INDIVIDUAL O LOCAL AGENCY =1 STATE-AGENCY = CORPORATION O PARTNERSHIP Q COUNTYAGENCY 0 FEDERAL-AGENCY i GITY 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 Milan) QINDIVIDUAL LOCAL AGENCY _1 STATE AGENCY CORPORATION PARTNERSHIP E-1 COUNTY AGENCY Q 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 M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BECOMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box blMkale 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 A SURETY DOND l� 5 LETTER OF CREDIT 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L ❑ II. ❑ III. ❑ 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) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY UL'✓� S CPYNH L_LJJIf JURISDICTION # FACILITY # O LOCATION CODE - OPTIONAL CENSUS T RONAL SUPVISOR - DISTfiICT CODE - CP THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAG� REGULATIO FORMA (393) ��/�JJ//'////''//// Y� � FOR00a3AA7