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• • PE50VR P. STATE OF CALIFORNIA ,? �'+•� STATE WATER RESOURCES CONTROL BOARD 3 ° UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °4nona�� COMPLETE THIS FORM FOR EAC ACILRYISITE ,yp� MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAO F CILITV NAME e O NAMEQFj �ATOR I S NEAREEft CROSS STREET PARCEL NIOPfIONAy CITY A L k1!//tl VJ✓ STATE ZIP COB): W6 SITE PHONE x WITH AREA CODE TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY D STATE-AGENCY 0 FEDERAL AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ❑ gESEIRVNDIAN #OFT S AT SITE E.P.A. I.0.#(optional) O 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA C F�F ] If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box loindicals INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY D CORPORATION Q PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY 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• ✓ box biMicala INDIVIDUAL OLOCAL-AGENCY DSTATE AGENCY (]CORPORATION O PARTNERSHIP D cOUNrY AGENCY FEDERAL-AGENCY CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE 7STORAGE FEE ACCOUNT NUMBER-Call 916 323-9555 if questions arise. IV. BOARD OF EQUALIZATIONUS ( ) TY(TK) HO 4 4] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMP ED)-IDENTIFY THEMETHOD(S) USED ✓box to indicate 0 1 SELF INSURED � UARATN 3INSURANCE L—]A SURETY BOND f] 5 LETTER OF CREDIT 6 EXEMPTION 1-1 0 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ I.❑ 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 MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY It Y JURISDICTION# FACILITY It LOCATION -OPTIONAL ICENSUB�RICaT# -OPJJpN� SUPVISOR- TRI TC DE -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. FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 A 33 6