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4 sssoun e c STATE OF CALIFORNIA �^ , STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3 o COMPLETE THIS FORM FOR EACH FACILRYISRE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT �T 6 CHANGE OF INFORMATION ❑ Y PERMA OSED SITE ONE REM ❑ 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 I ADDRESS f NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME S I STATE ZIP CO E� SITE PHONEI WITH AREA CODE TO DICATE —1 CORPORATION INDIVIDUAL [:D PARTNERSHIP 0 LOCAL- SENCY (] COUNTY-AGENCY QSTATE-AGENCY (] FEDERAL-AGENCY TYPE OF BUSINESS =] 1 GAS STATION 2 DISTRIBUTOR ❑ R SERVATIOONN #OF TAN KS�T SITE E.P.A. I.D.N(optimal) 0 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: ME(LAST,FfFIST) PHONE x WITH EA OE DAYS: NAME(LAST,FIRST) L140a WITH AREA COEIE NIGHTS: NAME(LAST.FIR T) HONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA Cool II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS babir&Ale 0 INDIVIDUAL E�j LOCAL-AGENCY Q STATE-AGENCY CORPORATION D PARTNERSHIP COUNTY AGENCY IM 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 MAILINGOR STREET ADDRESS ✓ bm b,Mkale INDIVIDUAL (] LOCAL-AGENCY L�j STATE AGENCY (]CORPORATION E:] PARTNERSHIP D COUNTY#GENCY 0 FEDERAL-AGENCY CITU 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) HOF4 [4:1- V. 4 1-V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Wm bin low 0 1 SELF INSURED O 2 GUARANTEE D 3 INSURANCE L__I 4 SURETY BOND LJ 5 LETTEROFCREDIT 0 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: I.O II.❑ III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY CO NTY a JURISDICTION# FACILITY# -1Z .OGATION CODE -OPTION iCENSUS TRA T♦ OP ONAL SUPVIS DI TRIC ODE -OPTIONAL G THIS FORM MUST BEACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,kjNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \\ FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR