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STATE OF CALIFORNIA 3 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3 o COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY NAME / NAME OF OPERATOR ADDRESSO /`�J� r /I D� NEAREST CROSS STREET PARCELRIOPfIONAy CITY NA/, STATE ZIP CO SITE PHONE%WITH AREA CODE ✓ BOX T I/ Box CORPORATION 0 INDIVIDUAL D PARTNERSHIP DISTRICTSENCY 0 COUNfV#GENCV STATE-AGENCY FEDERAL#GENCY TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN k OF TANKS AT SITE E.P.A. I.D.M(opfionali ❑ RESERVATION N O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS [/ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: NAME(LAST, RST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) ,MRS p1rf1A v9 WITH AREA CODE NIGHTS: NAME(LAS ,FIRST) PHOT, WITAREACOOE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• M7777R: NA /,4,A44 FORMATION MAILING OR STREET ADDRESS � INDIVIDUAL 0 LOCAL-AGENCY (]STATE AGENCYPARTNERSHIP O COUNfV#GENCY FEDEPAL-AGENCYCIN NAME STAT ODE PHONE p WIyTH AREA CODE �. K III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ME OF OWNS {J{' CAPE OF ADDRESS INFORMATION NA �� - ✓ MAILING OR STREET ADDRESS box bindkate INDIVIDUAL = LOCAL-AGENCY E7 STATE-AGENCY O CORPORATION PARTNERSHIP COUNTY-AGENCYFED RAL#GENCYZn f ✓L PHONE 9WITH AREACODE CITY NAME STATE ZIP CODy aAA-I-YGf ' 60 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQF4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindkate = I SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE L__j 4 SURETY BONG O 5 LETTEROFCREDIT I=6 EXEMPTION N 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.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTE08 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVIVEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCCATIONCODE -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL / ng �.Z THIS ORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OOR0033A 5 FORM A(5-91)