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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD :a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE °wtnow+" MARK ONLY F-1 i NEW PERMIT O 3 RENEWAL PERMIT1 CHANGE OF INFORMATION Q 7 PERMANENTLY C ONE REM Q 2 INTERIM PERMIT Q A AMENDED PERMIT O e TEMPORARY SITE CLOSURE �2(TFACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) D F 0.nY NAMERD OD 0 NAME OF OPERATOR QP� a ADDRE&9 / NEM TC BTREET PARCELS(OPTIONAL) 5a3 Sca 5 er CITY NAMF� 9TACA ZIP SITE PHONE a WITH AREA CODE `V G O TO INDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP (] LOCAL-AGENCY CDUNTYAGEMCY' O STATE-AGENCY• ED FEDERALaOENCY' DISTRICTS N Amer M UST Is a pubic agency,complete the following:nanta d Supervisor of aNbbn,Seclbn.W office which op warm the UST TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A I.D.a IAoeaetp = RESERVATION 3 FARM Q 0 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-apllonal DAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 6ROPERTY OWNER INFORMATION- UST BE COMPLETED NAME,—) /+ CARE OF ADDRESS INFORMATION V J\ MAILING OR STREET ADDRESS ✓ bar bbMbO INDIVIDUAL LOCALAGENCY STATE AGENCY Q O CORPORATION O PARTNERSHIP O COIINTYAGENCY O FEDERALAGENCY CITY NAME STA ZIPCODE WITH CODE PHONE a AREA CODE c�c PA / 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bot blNbYe 0 INDIVIDUAL E3 LOCAI.AGENCY 0 STATE AGENCY O CORPORATION PARTNERSHIP Q COUNTY-AGENCY =)FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EOl1A EE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO F4-T4--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ babes Q 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE a SURETY BOND D 5 LETTER OF CREDIT ED e EXEMPTION 92 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: I.[::] 11.0 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED 6 SIGNED) OWNER'S TITLE GATE MONTHA7AYNEAR LOCAL AGENCY USE ONLY D COUNTY It JURISDICTION a m: 5 CENUSTi - TROPTIONAL-OPTIONAL �N cl THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE I FOR� x`�/� OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM ' 6 47 st- to rw } / /� y� � �� b://a #4c c-