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STATEOFCAUFORMA .� STATE WATER RESOURCES CONTROL BOARD 3., UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE ee." MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE TE ) ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE 6 I I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) FORA OR FACILITY NPM NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCELII(OPTIONAL) l� CITY NAM STATE ZIP CODE SITE PHONE i WITH AREA CODE G CA Z TOO/ Box xTE O CORPORATION �INDIVIDUAL 0 PARTNERSHIP � LOCAL-AGENCY 0 COUNrYAGENCY' O STATE-AGENCY' 0 FEDERALAGENCY DISTRICTS' II owner d UST Is a pubic agency,conplate,the following:name of Supervisor of division,section,m office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOfl O ✓ IF INDIAN i OF TANKS AT SITE E.P.A. I.O.i(optiarra# RESERVATION 3 FARM 0 4 PROCESSOR [9f6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i 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 ADDRESSr I 1 � ✓ Eos bintlkab � INDIVIDUAL I� LOCAL-AGENCY ED STATE AGENCY 7l �I p" _ iJ ZAYJJ_�- <21 CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY CIATjX�/G'TQ STATE ZIP CODE PHO VNE i WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 9 NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET AE5DRESS ✓boa bindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY J 5 � [n`C`OflPoRATION O PARTNERSHIP 0 COUNTY-AGENCYD FEDERAL-AGENCY Aj,4;?zd IAC NAME9TATE ZIP CODE-:7 COOD` PHONE i WITH AREA CODE S;v IV.BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO F4]4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa birdkzts 0 I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND O 5 LETTER OF CREW 0 6 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] I. III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&S IGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# -4T LOCATION CODE -OPTIONAL CENSUSTMgqCTi •OPTIONAL 9UPVISOR.DISTRICT CODE -OPTIONAL �• 3L� THIS ORM 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 FOI10037Afl] FORM A(310 OWNER 0