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STATE OF CALIFORNIA �..i 'c ``s, STATE WATER RESOURCES CONTROL BOARD s'w� "� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A Chan ry1 COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE (IMA I. FACILTfY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAO ,AGILITY NAM l,,,,h Wm NAME OF .PZOR ADORIS`0 IY NE R SSTT.•ICROSSST EET PARCEL0(OPfpNAU lU 5 .eek" asemi�e, CITYNAµE CK 4-m 3 CA ZIP CODE ITE PHONE i WITH AREADE / TINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY D6TRCT5 TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR O flESERV✓ IF INADIAN I OF TANKS AT SITE E.P.A. I.D.0(gNMAA) WDS ' Q 3 FARM Q 6 PROCESSOR ANDS 5 OTHER pR TRUST L EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE/WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓babbOkaM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL- AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Aoabinl = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTYAURCY Q FEDERAL- AGENCY CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Gall(916)323.9555 if questions arise. TY(TK) HQ 4 4 D 2 2- Z 1� Y�Yvlovtn 0L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ,�Om b'vglNla Q I SELF-INSURED Q GUARAMEE Q 3 NSURANCE Q A SURETY BOND Q 5 LETTEROFCREDIT 8 EXEMPT ON Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or HI's checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1,❑ II.❑ III.❑ 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY x JURISDICTIONISUP�ITIR�Z�DIISTRICT p ODE ® p )►� ql LOCATION C -OPTIONAL CENSUS TFACCTa -QPn NAL CODE -OP THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91)