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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A fCOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 0 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAO FACILI NAME NAME OF OPERATOR �a F F. , ,� ADDRESS s� NEAREST CROSS STREET PARCELO(OFnONAU CIN NARE I I STATE ZIP CODE SITE PHE#WITH AyEA CODE CAI/ Box �1 T9v Z TO INDICATE 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' DISTRICTS' 'If owner d UST is a public agency,complete the following:name of SUPONbOr d dNislon,section.or duce which operates the UST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a icp oral) ❑ 3 FARM 4 PROCESSOR 6 OTHER RESERVATION❑ OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a 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 ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME j CARE OF ADDRESS INFORMATION O MAILING OR STREET ADDRESS i I ✓ box olyd"s, 0 INDIVIDUAL LOCALAGENCY 0 STATE-AGENCY F•J 0 CORPORATION ID PARTNERSHI COUNTY-.AGENCY O FEDERAL-AGENCY CITY NA STATE ZIP CODE HONE a WI H AREA CO E III. T NK OWNER INFORMATION-(MUST BE COMPLETED) NAMED OWNE �, CARE OF ADDRESS INFORMATION /`/a��Q MAILING OR STREET ADDRES7 I ✓box blMkate 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY �/A,4 nj`7j X 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY-NAMCITY-NAMF STATE ZIP CODE I PHONES VJITH AREA C E r / -rot '6 wiezz zEtz-ZsIdv IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ F4-T4--] p V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓how bintlkale O 1 SELF-INSURED O 2 GUARANTEE D 3 INSURANCE O 4 SURETY BOND 0 5 LETTEROFCREDIT O 6 EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I/ C or�It_is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] y.STIII.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORK T OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION A FACILITY/ LOCATION CODE -OPTION CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 32v THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INF FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAT