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'esoua e STATE OF CALIFORNIA r< co STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w�� e � . o O�M,� COMPLETE THIS FORM FOR E FACILITYISITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA R ACILI NAME v NAME OF ERATDR /J art' RE A S NEA RES ROSS STREET /v�'rJ ARCELNIOPFIONAy CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE CABOX �ZD3 TO INDICATE D CORPORATION O INDIVIDUAL Lf PARTNERSHIP 0 LOCAL AGENCY COUNTY-AGENCY [_1 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 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) PHONE#WITH AREA CORE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITHARIFACOC II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) NAME v CAR F ADDRESS MFORMATI n MAIL) STREET ADDR ✓ boxbiiM' 0 INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAM STA ZI OD HONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ' NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bm In indicate INDIVIDUAL 0 LOCAL-AGENCY (]STATE AGENCY 0 CORPORATION D PARTNERSHIP O COUNTY-AGENCY L-I FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ [4:[4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓ bm P,ndi ate I SELF JNSURED 0 UARAMEE IL 3INSURANCE � 4 SURETY BOND 5 LETTEROFCREDIT 6 EXEMPTION L] S9 OTHER Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II IS ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.V III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION# FACILITY# ttzz tt 9 CMZ LOCATION GO E �OPTIONAL CENSUS TRA 1_=O�yOyQL SUPVISOR T C CODE -OPT) N THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,LINLEAS THIS IS A CHANGE OF SITE INFORMATION 0 LY. FNM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS • FOR0033AP6