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STATE OF CALIFORNIA �0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ' �r COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY F--] I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLO�� ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BECOMPLETED) EOFOPERATOR r8ARITY NAME PI(,CU^ PARCELalOPONAuNEAREST CROSS STREETI G ('� O $TATE ZIP CODE SITE PHONE a WITH AREA CODE\ _ CVC�0 CA JC7 Dj CORPoMTION INDIVIDUAL PARTNERSHIP QLOCAL-AGENCY l3 COUNTY-AGENCY' O STATE.AGENCY' O FEDERAUAGENCY' E DISTRICTS' '11 oener d UST ie a public agent wnplele the 1ollovdnB:name of Supervisor of division,section,or office which operates the UST ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.#(optional) TYPE OF BUSINESS 1 GAS STATION ❑ 2DISTRIBUTOR RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-op 111 [NIGHTS: (LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE ME(LAST,FIRST) PHONE WITH AREACODE NIGH TS:NAME(LAST.FIRST) PHONEa WITH AR EA CO DE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION LNAMEj0(4bosbindkdeTREET ADDRESS INDIVIDUAL LOCALAGENCY STATE-AGENCY CORPORATION O PARTNERSHIP �COUNTRAGENCY El FEDERAL-AGENCY PHONE a WITH AREA CODE STAT ZIP COD_EM/� os , /�5 4 (!dC/ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF AD DRESS INFORMATION I� f NAME OFO NER MAILINa OR STREET ADDRESS ✓boa birdiraw ED INDIVIDUAL El LOCAL-AGENCY STATEAGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY iZIP CODEPHONE a WITH AREA CODE- CITY ODE CITYN S za99—S� / W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if queslions arise. TY(TK) HQ F_4-R- V. 4- - D 0 0 5 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMP COMPETED)—IDENTIFY THEMETHOD(S) USED 1 SELF INSURED FZ 2 GUARANTEE O 3 INSURANCE O A SURETYBOND ✓ bmbirdkale 0 5 LETTEROFCREDR 6 EXEMPTION 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 ch 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 OWNEWS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWOAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL S VISOR-DISTRICT CODE -OPTIONAL ell, SW G- (O THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM Br UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORa M-137 FORM A OW) �-