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y boV- F�' C STATEOFCALIFOANIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A I� COMPLETE THIS FORM FOR EACH FACILITYISITE L MARK ONLY J t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY G ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) r)RA OR FACILITY NAME NAME OF OPERATOR ADDR SS NEAREST CROSS STREET PARCEL#(OPTIONAL) /g l FL19 S!g CITY NAME // STATE ZIP CODE SITE PHONE#WITH AREA CODE �44 — 3 BOX CORPORATION l�INDIVIDUAL Q PARTNERSHIP [] LOCAL-AGENCY 0 COUNTY-AGENCY` 0 5TATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE _ DISTRICTS' If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR IF INDIAN #OF TANKS AT SITE E.P.A. 1-D.;V(optional) RES✓ERVATION C] 3 FARM 0 4 PROCESSOR FV 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DA S: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE & 1a 9 NIGHTS: NAME(LAST.FIRST) 01 PHONE#WITH AMA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUS_T BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box toindlcals © INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY [—j CCRPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY 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 indlcato 0 INDIVIDUAL L--) LOCAL-AGENCY (] STATE-AGENCY Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY L__1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONES WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO [4]-4-]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box ID indicate 0 I SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND 5 LETTFR 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 11 is checked. [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. if.Q Ill. THISFORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER•STITLE DATE MONTHIDAYNFAR LOCAL AGENCY USE ONLY c— 1—D JL3 A g 6 f COUrnNTY# JURISDICTION# FACILITY# '— :1 LOCATION CODE -OPTIONAL CEN TRA T# •OPTY NA SUPVISOR-DISTRICT CODE -OPT70NAL 22 THIS FOFAI MusT BE ACCOMPANIED 8Y ERMIT 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 FORMA{3193} FQ3A�1