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er'W- STATEOFCAUFORMA - `., STATE WATER RESOURCES CONTROL BOARD i��, a ii UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , a COMPLETE THIS FORM FOR EACH FACILITY/SITE w�-y� '�-�„a,,,,;• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE r - I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORF CI ITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPf10NA4 CITY NAME S STATE ZIP CODE � SITE PHONE#WITH AREA CODE ✓aoz TOINGCATE 0 CORPORATION O INDIVIDUAL D PARTNERSHIP Q LOCAL-AGENCY 0 COUNryAGENCY. Q STATE AGENCY' FE FEDERM-AGENCY• B a,ner Of UST is a public agency,WMPNNe the following:name of SYP#Nbor of dDISTRICTS t✓kbn,aeclbn,or ICT which operates the UST TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN i OF TANKS AT SITE E.P.A. I.D.#(opbnwJ ❑ 3 FARM ❑ 4 PROCESSOR5 OTHER ❑ RESERVATION OR TRUST LANDS =INFORMA GEN CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional ) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NER INFORMA ON- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OflSTREET ADDRESS - ✓bm bYgkas Ell] INDIVIDUAL O (DCALAGENCY E:1 STATE AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY ED FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 111. TANK OWNER INFORMATION-(MUST BEC PLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILINGORSTREETADDRESS ✓box birdbaN 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY D CORPORATION =PARTNERSHIP COUNTYAGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT N BER-Call(916)322.9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bib O 1 SELF-INSUREDO 2 GUARAMEE O 3 INSURANCE O 1 SURETY BOND L:1S LETTER OF CREDIT O 6 EXEMPnON E--3 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be ent 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.❑ Il.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED B SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY G '505111 COUINTY# JURISDICTION# FA(ATTY• L -T LOCATION CODE -OPT/ONAL CENSUS TRACT# -OPTIONAL SUPVISORTRICT •OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO�IND STORAGE TANK REGULATIONS / (393) FOROOOM AI l