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0 'UbpU9 , STATE OFCAUFCRMA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A t COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATDN�7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT E] e TEMPORARY SITE CLOSUR I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA0 ,q1CILITY NAME { O NAME OF OPERATOR ADDRESS� ... J -� , / N REST CROSS STREET a PARCELx(OPfDNAU 0 CIN NAMES fJ � STACA ZIP CODE / SITE PHONE t WITH AREA CODE ✓ Box TO INDICATE E:]CORPORATION O INDIVIDUALPARTNERSHIP (] LOCAL-AGENCY O COUNrY-AGENCY' O STATE-AGENCY' O FEDERAL.AGENCY' DISTRICTS' •If saner of UST Is a public agency,complete the following:name Supervisor of division.section,or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D. fopl/cnal) RESERVATION ❑ 3 FARM ❑ 6 PROCESSOR 5 OTHER OR TRUSTLANOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) — PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bwbindicale =1 INDIVIDUAL E::] LOCAL-AGENCY E::] STATE-AGENCY CORPORATION O PARTNERSHIP E:I COUNTYAGENCY Q FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxicindicals E:1 INDIVIDUAL O LOCAL-AGENCY =STATE-AGENCY D CORPORATION 0 PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY CIN 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 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bintlkale 0 1 SELF-INSURED 2 GUARANTEE ❑ 3 INSURANCE D 5 LETTER OF CREDITED e SURETY BOND 6 EXEMPTION F-1 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.❑ 11.❑ 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&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY R COUNTY# JURISDICTION If FACILITY# LOCATIONCODE -OPTIONAL CENSU I TXACTa -OP NAL SUPVISOR-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. FORM A(31113) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 FOROMM-117