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-60V- f STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT AP ICATION-FORM A COMPLETE THIS FORM FOR EACH F LITYISITE i MARK ONLY T NEW PERMIT F--j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 (PERMANENTLY CLOSED SITE ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION 8 ADDRESS-(MU$T BE COMPLETED) r)RA OR FACILITY NAME E OF OPERATOR ADDRESS O / EAREST CROSS STREET PARCEL#(OPT - - CITY NAME STATE ZIP CO / SITE PHONE#WITH AREA CODE CA i NgBOX CATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP ,LOCAL-AGENCY Q ODUNIYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' STRICTS' 9 owner d UST is a public agency.con Plete the fo9pwing:nane of SupervYor of division, ion, r oMim which operates the UST TYPE OF BUSINESS O L GASSTATION Q 2 DISTRIBUTORRESERVADDIAN 1#OF TANKS AT SITE E.P.A. I.D.0(Andonap Q 3 FARM A PROCESSOR S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ ism bintlleae INDIVIDUAL [=1 LOCALAGENCY El STATE-AGENCY CORPORATION (] PARTNERSHIP 0 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 ✓ism bbAca# El INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY Q CORPORATION 0 PARTNERSHIP COUKTYAGENCY (]FEDERAL-AGENCY CRY NAME STATE 21P 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 ✓bm b Indicate D I SELF-INSURED O 2 GUARANTEE 3 INSURANCE O A SURETY BOND O 5 LETTEROFCREDT O IT EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE,IS TRUE AND CORRECT OWNE RS NAME(PRINTED e S IGNED) OWNER'STITLE DATE MONTHIDAYN LOCAL AGENCY USE ONLY a COUNTY AT J� � FACIL LOCATION CODE -OPTIONAL CENSUSTRACT41 OP SUPVISOR-DISTRICT CODE -OPTIONAL 7: 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 UNDERGROUNQSTORAGE TANK REGULATKRIS FORM A(393) -- FCR=MmR7