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STATE OF CALIFORNIA �r•�� ` STATE WATER RESOURCES CONTROL BOARD '��, .,• e� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLO ONE REM ❑ 2 INTERIM PERMIT ❑ I AMENDED PERMIT O S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR ILnY'N E NAMEOFOPERATOR2��/�� ADDRESS , �-`� `� 1 ' ✓ // 1 �IC/ A NEARFyST ROSSSTREET PARCEL#(oPrpNAL) CITY NA E STATE ZIP CODE SITE PHONE i WITH AREA CODE ✓ x CA Bo TOINDICATE RRTRATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY Q SPATE-AGENCY' Q FEDERAL AGENCY owner of UST Is a public agency,wnpipe h Iollwinp:nartg of Supervisor of • UNbbn.cectbn,or oxiw which operates the LIST TYPE OF BUSINESS ❑ I GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#gpam" 0 3 FARM = A PROCESSOR 5 OTHER RESERVATION O OR RESERVTRUST ANOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opttaW DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGH NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ ba bin icats Q INDIVIDUAL Q LOCAL.AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q 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 ✓ba binEkab Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓by bin kale Q 1 SELF INSURED Q 2 GUARANTEE Q S INSURANCE Q I SURETY BOND Q 5 IETTEROFCREDIT Q S EXEMPTION 099 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ 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 It SIGNED) OWNER'S TITLE DATE MONTHDAYNEAR LOCAL AGENCY USE ONLY Z P CW�NTY# JURISDICTION p FACILITY# all Fm 161� LOCATION CODE -OPTIONAL CENSUS TRACT 0 - SUPVISOR-DISTRICT CODE -OPTIONAL or THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLJCATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS y2700 J/ V tom, i