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'L50Jw P4 STATE OF CALIFORNIA S P STATE WATER RESOURCES CONTROL BOARD w,ate- •• UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ?n � o; C�II.OPN.� COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY El 1 NEW PERMIT ❑I 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION _ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTE IM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) OBAOR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) �Jf� i/son �✓ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA °1S Zv TO INDICATE (]CORPORATI N INDIVIDUAL D PARTNERSHIP LOCAL DISTRICTS AGENCY Q COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY TYPE OF BUSINESS O I GAS S ATION 2 DISTRIBUTOR ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#/optional) ❑ ❑ RESERVATION O 3 FARM 4 PROCESSOR O 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) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAMESQ MAILING OR STREET ADDRESS ✓box bindkate INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY Pr Q 0 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITYNAME •! I STATE ZIP CODE PHONE#WITH AREA CODE c,/CrSrcfl 91S/7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING ORSTREET ADDRESS ✓ box b [_1 INDIVIDUAL LOCAL AGENCY (] STATE AGENCY 0 CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO L4 ]-[g V. PETROLEUM UST FIN NCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED 1 SELF-INSURED D 2 GUARANTEE 1� 3 INSURANCE O d SURETY BOND ✓ box m indicate 5 LETTER OF CREDIT 6 EXEMPTION CJ 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 check CHECK ONE BOX INDICATING WHIC ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.EV'III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ON Y COUNTY# JURISDICTION# FACILITY# S0N/eakc- gam -- `i 1 LOCATIONCODEOPTIONAL (CENSUS TRACT# TIONAL ISUPVISOR-DISTRICT CODE -OPTIONAL L -OP (743 3 2-3 THIS FORM MUST BE ACCOI IPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12.91) FILE 1 HIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STOR ANK REGULATIONS FOR0033A RB F40 . S '1(c) q 0 11��G3