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esooa ea STATE OF CALIFORNIA J STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETETHIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION X 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPERATOR ADDRESS F H NEAREST CROSS STREET PARCEL#(OPTIONAL) IJP C1v/�-�A�- O CITY NAM STATE 21P� SITE PHONE#WITH AREA CODE CA ES TNDIBOX CATE O CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL AGENCY O COUNTY-AGENCY STAT -AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O i GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#roPNm.1) RESERVATION 0 3 FARM [7] 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CnDP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) NAME I_ CARE OF ADDRESS INFORMATION V/- MAILING ORSTREET ADDRESS ✓box In mikam E::] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY D /fid E=1 CORPORATION Q PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY CIN NAME— STATE ZIP CODE HONEj WITH R`CJa1 DE _ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 7 / Z NAME OF OWNER CARE OF ADDRESS INFORMATION MAIL) OR STREET DRESS ✓box mindkam 0 INDIVIDUAL 0 LOCAL-AGENCY (� STATE AGENCY • D D CORPORATION O PARTNERSHIP O COUNTY-AGENCY = FEDERAL AGENCY CITY NAME STATE ZIP CODE HONEWITH AREA C E — L IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•h1l(916)323-9555 if questions arise. TY(TK) HO L4 4]-=_= V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boxmiMicale 1�� ISELFINSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT O 6 EXEMPTION CJ 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.❑ 11. U. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PR INTER 8 SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# w �/ LOCATIONCODE OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISR-DISTRICT CODE -OPTIONAL THIS F RM MUST BE ACCOMPANIED BY ATAT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FNM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033AR6