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STATEOFCAUFORNA • �� '� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA ORF I AME NAME OF OPERATOR ADDRESS ac NEAREST CROSS STREET PARCELAIOWIONAD CITU NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE I/ CA z O Z-0 - 77- // T 10 NDI ATE CORPORATION E::] INDIVIDUAL 11 PARTNERSHIP (] LOCAL-AGENCY Q COUNTY AGENCY' ED STATE AGENCY' =FEDEMLAGENCY' 11 owner of complete is a public agenccomplete the following:name of Supervisor of division.section,or oaios which operates the UST TYPE OF BUSINESS = 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(optiona() RESERVATION = 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE s NIGHTS: NAME(LAST,FIRST) PHONE#WIT AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM%O/ �� t �. /q / CARE OF ADDRESS INFORMATION MAILING OR EETAIADDRES l/•.Y/Y ✓borbl ate INDIVIDUAL OLOCAL-AGENCY STATE- AGENCY S �- ORPORATION = PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY N PH STATE ZIP C DE A ONE 1'W ITH AREA CODE c,* V III. TANK OWNA INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ iMkab INDIVIDUAL 0 LOCAL-AGENCY lj STATE AGENCY CORPORATION Q PARTNERSHIP =CoUNry-AGENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ F4-T4--]- V. 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓ box biMkale 1 SELF-INSURED [:712 GUARANTEE 0 3 INSURANCE O 4 SURETYBOND 5 LETTEROFCAEDIT E-1 6 EXEMPTION C�l 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is ch ked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. It.W. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COOOUN/may/TYY# JURISDICTION# FACILI®TY Ii - LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTpNAL b—/� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OhLY. FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033ATI7