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..� 'tedyn C STATE OF CALIFORNIA "� o t" STATE WATER RESOURCES CONTROL BOARD ` UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A ', COMPLETE THIS FORM FOR EACH FACILTTYISITE �•o�"'' MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO ONE REM F7 2 INTERIM PERMIT 6 AMENDED PERMIT 0 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME) NAMED OP RATO Ej-d A RESS � N EST ROSS STRE PARCEL#(OPTxONAU a CITY NAM STATE 2IF CODE S PHONESWITH AREA CODE f Ca ao 9 0 r 1NDIICCAT 0EI.aI CORPORATION O INDIVIDUAL O PARTNERSHIP l� LOCAL-AGENCY COUNIFY-AGENCY' O STATE AGENCY O FEDERALAGENCY'D/ - DISTRICTS' X avert d UST is a pu 9c agency,MnpMle the[0110 ng:name A Suprtvbor ol division,section,or oNIM whbh operates the UST TYPE OF BUSINESS = 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN INOFTANKS AT SITE I E.P.A. I.0.0 Icprmal) 3 FARM Q # PROCESSOR 5 OTHER OR RESERVATION TRUST LANDS7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: AME(LAST,FIRST) PHONE#WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE RA Cao - W NIGHTS: NAME(LAST,FIRST) PHONE#W1I H AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bet bintlkm 0 INDIVIDUAL D LOCAL-AGENCY O STATE-AoENCY O CORPORATION O PARTNERSHIP D COUNTY-AGENCY 0 FEDERALAGENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA COOS III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Ewblydb 0 INDIVIDUAL D LOCAL-AGENCY D STATE.AGENCY O CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bos b NldNb1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE E-AA SURETY BOND AS, OF CREDIT 0 S EXEMPTION 0 99 OTHER A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATXONS AND BILLING: I.x II.O In.Q 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) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUUNTY# JURISDICTION FACILITY# L/ Al LOCATION -OPTIONAL CENSUSTRACTS -OP L SUPVISOR-OISTRICTCOOE -OP I " 110 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE RFORMATKIN ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 40