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STATE OF CAUFORNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Y� a COMPLETE THIS FORM FOR EACH EACILrTYlSITE MARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 AN OSEO SR ONE REM F-12 INTERIM PERMIT c:14 AMENDED PERMIT a TEMPORARY SITE CLOSURE CI L FACILrTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR / ADDRESS N� NEARESTC SSSTREET PARCEL 0(OPTONAU CITY NAME VY STATEZIP�5, SITE PHONE t MTN AREA CODE 1� CA -/ S D ToINDICATE Ap CORPORATION Q INDMAL p PARTNERSHIP p LOCAL-AGENCY p COUKrY.AGENCY p STATE-AGENCY p FEDERAL AGENCY DISTRICTSTYPE vF 3USINESS I GAS STATION J 2 DISTRIBUTOR = ✓ -F INDIAN I Of TANKS AT SIiE E.P.A. LO. (PP wv) D FARM A PROCESSOR 5 OTHER RESERVATICN C OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional JAYS: NAME(LAST,FIRST) PHONE P WITH AREA CODE DAYS: NAME(LAST,FIRST) .NIGHTS: NAMEtLAST.FIRST) PHONE 8 MTN AREA CODE NIGHTS: NAME(LAST.FIRST) o , c.WrTH AREA Cc II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF AOCAESS INFORMATION MAIL.`NG OR STREET ADDRESS I J 1m 0v P, 1 ;rygypUAL I_ p LOCAL AGENCY L.: S1A7E.AGENCV CORPORATION p PARrNERSMP p COUKrYd AmCN Cj FEDERALAGENCY C,11 NAME I 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 J om onorAM p IKXV10UAL p LOCAUAOFNCY p STATE466 CY p CORPORATION p PMTNERSMP p COUNTYJGENCY p FEDFIMLAGENC/ CITY NAME STATE ZIP CODE PNONE t WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. TY(TK) HQ 4 4 -� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED i SELFJNSURED a 2 GUARAKrEE p 2 NSURAKLE p •SURETY BOND 0 5 LETTER OF CREW p A ExEWmR p 9i OTHER VL LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IL is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ R❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLOANTS NAME(PRINTED a SIGNATURE) APPLCANTS TITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY R - I I JURISDICTION a FACILITY e LOCATION CODE -OPTNONAL ICENSSUST -OPM)ALAL SUP jV ;0 06TR11'.L600E -OPTgNA1 THIS FORM MUST BE ACCOMPANIED BY VY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE WFORMATION ONLY. FORM A(SBI) FORDA13"