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//^ • STATE OF CALIFORNIA • 'A STATE WATER RESOURCES CONTROL BOARD # ear F UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILRY/SITE „a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION n' 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA,Of1 FACILITY AME / NAME OF OPERATOR AD DR $, / EST CRO TR ET PARCEL#(OPTIONAL) G CITY N,i IAE� / STATE ZIP E / P ON W AREA D CA I TO INDI ATE O7`CO�RPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCYW CMKAGENCCY//^ O STATE-AGENCY, FEDERALa�GENCY' ' If owner or UST is a public agency,wmplde the following:name of Supervbor of tlNissection.DISTRICTS'n,e9n,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TAN4S AT SITE E.P.A. I.D.#(optimal) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS it EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST( PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS '�;'. V bexbinEbaU E:3 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY O CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY CITY NAME ✓ V STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box toinicate [:j INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY O CORPORATION = PARTNERSHIP E-3 COUINY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4--F4-I-'-�/ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓ box badhale 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE lj 4 SURETY BOND D 5 LETIEROFCREDIT 6 EXEMPTION Q 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 OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY CON # JURISDICTION If FACILITY# Lam] ?� 7 �� LOCATION CODE -OPTIONAL CEN SUS TRAC'T� �/.1P, 9UPVISOR DISTRICT CODE -OPTIONAL 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 REGULATIONS• Fp1007AAT 0