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i itl � `baup r STATE OFCAUFORNIA STATE YVATER RESOURCES CONTROL BOARD r•��' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLO ' ONE ITEM 2 INTERIM PERMIT � 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA FACILITY DIME NAME OF OPERATOR ! NEAREST CROSS STREET PARCEL If(OPTIONAL) 4DE , CIN NAM f 7TACTE ZIP CODE SITE PONE#WITH AREA CODE I �,,{ ✓ �X CORPORATION [� INDIVIDUAL IfTPARTNERSHIP LOCAL-AGENCY Q COUNTY•AGENCY' STATE-AGENCY L� FEDERAL-AGENCY' TO#NOICATE 0 �\ DISTRICTS' if owner of UST fs a publdc agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONEII WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST} PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box fo indicate 0 INDIVIDUAL 0 LOCAL-AGENCY [] STATE-AGENCY I�CORPORATION E__1 PARTNERSHIP ®COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARVE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY []CORPORATION C] PARTNERSHIP 0 COUNTY AGENCY Q FEDERAL-AGENCY CITY NAME STATE 21P CODE PHONE#WITH AREA CODE IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 R- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED Fbm bindcate = I SELF-INSURED [:_12 GUARANTEE [� a INSURANCE ( []4 SUP BOND Q 5 LETTER OF CREDIT ID 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 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 CF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY Ez _L c , Y_ COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL 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 FORMA{3"93) fC1fN f� �,