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STATE OFCAUFORMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , COMPLETE THIS FORM FOR EACHFACILITYISITE MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM F-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAORFACILITY NAME NAME OPERATOR 0L -y- . O ADDRESS NEA ST CROSS STREET I PARCEL#(OPTgNAU yy 91Z a*47 CITY NAME STATE ZIP CODE SITE PHONE S WITH AREA CODE TOINDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCY' L::)STATE-AGENCY' E] FEDERAL-AGENCY' DSTRICTS' 'It owner d UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates,the UST TYPE OF BUSINESS Q t�STATION 2 DISTRIBUTOR 0 ✓RESERVATION INDIAN #OF TANKS AT SITE E.P.A. I.D.#rapr/onag IBJ/ 3 FARM RESER4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS- NAME AST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIG : NAM (LAS FIRST) V PHONE#WITH AREA CODENIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE 7 3E G II. PROPERTY OWNER IN ORMATION• MUST BE COMPLETED NAME CARE OF ORE6 INFORMAIIONJ^ o6 � /'6vM'3 MAILING OR STREET ADDRESS ✓ box to lnEbale r 0 INDIVIDUAL D LOCAL-AGENCY = STATE-AGENCY k ORPORATION O PARTNERSHIP E:J COUNTY-AGENCY O FEDERAL-AGENCY CITY M STA�E,yT� ZIPCODE , PHONE#WITH AREA CODE Li /v U{v III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWN CARE OF ADDRESS INFORMATION )) MAILING OR STREET ADDRESS ✓ box bindic" O INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY 0 CORPORATION PARTNERSHIP COUNTY-AGENCY E�:] FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- -LI V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box b Indicate I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND D 5 LETTER OF CREDIT &EXEMPTION I1 99 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 OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY CaOUNI�TY I# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL ® 9UPVISOR-DISTRICT CODEE -OP� r� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE 1AFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) - FOROMM-117