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♦r C STATE OF CAUFORWA STATE WATER RESOURCES CONTROL BOARD ; UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A .j - COMPLETE THIS FORM FOR EACH FAC1UTY/SITE `•x�ta#"" MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE -' I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRE3Sp _7 NEAREST CROSS TREEETn PARCELN(OPTIONAL) 4A LC CITY NAME STATE ZIP CODI SITEPHONE#WITH AREACODE GiTl� CA �T//9 It v il)�/y —/22 Z ✓ BOX • PARTNERSHIP O LOCAL-AGENCY O COUNTY#eENCY' O STATE-AGENCY' ED FEDERAL-AGENCY' TOINDCATE :�CORPORATION O INDIVIDUAL O DISTRICTS' I owner d UST Is a Pubic agency,complete the following:name of Supervisor of division,sedan,or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ RV IF INDIAN NOF TANKS AT AT SITE E.P.A. I.D.#(ophona RVATION ❑ 3 FARM ❑ 4 PROCESSOR 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAY/S:: NAME(LAST,FIRST) o ( PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE /d , -moi A L w' _ �. NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME -> �—� <�C (._ CAREOFtDIy INIE �Mv MAILING OR STREET ADD ✓bat b W&AN Q INDIVIDUAL O LOCAL-AGENCYE]E] STATEAGENCY /� / IL G•�/C /��jA ✓ a✓F I�CORPORATION [::] PARTNERSHIP CD COUNTY-AGENCY FEDERAL-AGENCY CITY A-M$ ^ S 45 ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMVF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS / ✓ box bindicale 0INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY //; ' CORPORATION L-I PARTNERSHIP O COUNTY-AGENCY E-1 FEDERAL-AGENCY CITY NAME STA ZIP CODE PHONE#WITH AREA CODE S !J 74r_j/ IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ oox bintlicafe I� I SELFINSURED 0 2 GUARANTEE 0 3 INSURANCE [-14 SURETYaONO D 5 LETTEROFCREDIT E=1 N EXEMPTION 0 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 MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION III, FACILITY# /y- LOCATION CGDE -OPTIONAL CENSUSTRACT# OPTIONAL S1 ISOR;DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) • • FOR0039AA7