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e�w STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD / UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACHFACILITYSITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S� I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMNAME OF OPERATOR C ADDRESSOC rG �\ NEAREST CROSS STREET PARCEL 0(OFrIDNAO D 10 /1 CITY NAME n STATE ZIP CODE SITE PHONE a WITH AREA CODE CA 5'566 TO INDICATE I�PDRATION I]INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAUAGENCY' DISTRICTS' If owner of UST Is a Public agency,complains the following:name of Supervisor of division.section.or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN Ilf OF TANKS AT SITE E.P.A. I.D.a(optimal) ESEQ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER ORTRUSTVATION LANDS 0 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 NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME 2 OU l�t'sr� CARE OF ADDRESS INFORMATION MAILING OR STREET RESS ✓boa bindimm INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY 0 CORPORATION Q PARTNERSHIP (] COUNTY-AGENCY FEDERALAGENCY CITY NAME STFE ZIP CODE PHONE x WITH AREA CODE \ ( `� 95366 III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION La✓1 CZ S MAILING OR STREET ADDRESS ✓ baa to indicate INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ [4147- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ lwxbiMkate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSUR Q A SURETY BOND O 5 LETTEROFCREDIT 0 6 EXEMPTION W 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. CHECKONE 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 B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION If FACILITY 0 mu / & F LOCATION CODE -Cor CENSUS TRACT* -OP77ONAL 9UPVISOR-DISTRICT CODE -OPT70NAL I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATON I; • . /��/ 1//�M� FOR0033AA7 I