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• STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD s m� <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ///% ,• <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> LM <br /> ARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT Ej 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> EONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT EJ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D A <br /> CIL ITYNNAMEOFOPERATOR <br /> AD R SS I/ G NE 9/T�CRry0333ST EEET� PARCEL#IOPFgNAQ <br /> 111 (.G/I N/ v' <br /> CITY NA Ehm 9TACA ZIP q/ SITE PHONES WITH AREA CODE <br /> v BOX <br /> 701NDICATE 0 CORPORATION O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCYCAUMY-AGENCY <br /> DISTRICTS' 0 STATE-AGENCY' 0 FEDERAL AGENCY <br /> M owner d UST is a public agency,complete the following:name of Supervisor of division.sedlon,or O"Im which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #0F TANK AT SITE E.P.A. I.D.#(oplAnall <br /> 0 3 FARM 4 PROCESSOR RESERVATION <br /> O 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME LL 1,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ molmum 0INDIVIDUAL 0 LOCAL-AGENCY E STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME vw I I STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindRate INDIVIDUAL 0 LOCA AAGENCY 0 STATE AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boxbindkae 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> O 5 LETTEROFCREDIT D e EXEMPTION (]83 OTHER D A SURETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II Is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OW NEWS NAME(PAINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION ArFACILITY# <br /> P12 2 3 2 2 <br /> LOCATIO -OPTIONAL CENSUS TRAM T 9UPVISOR-D T -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORV <br /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION( <br />