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a6 e ^ STATE OF CALIFORNIA ^e STATE WATER RESOURCES CONTROL BOARD .mg ae UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , 'p /r COMPLETE THIS FORM FOR EACH FAGLITYISITE `"�^°""�^ MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE Ra EM 2 INTERIM PERMIT 4 AMENDED PERMIT �S TEMPORARY SITE CLOSURE 5 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR F/AjCILI�TY NAME ` 1 NAME OF OPERATOR C?'� /4/ 72 ADDRESS NEARESTCROSS STREET PARCEL 0lOPTIONAU CITY NAME STATE ZIP CODE ITE P NE a WITH AREA CODE CAS 7i7 �/ —� TI/ BOX O CORPORATION El INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY �COUNrY-AGENCY' I�STATE.AGENCY' = FEDERAL-AGENCY' DISTRICTS' X owner N UST Is a public agency.complete The following:name of Supervisor W division,sesdon,or office which operates the UST / IF INDIAN TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATION AOF TMy(S AT SITE E.P.A. I.D.a(°Wbnap = 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DA NAME(LAST,FIRST) PHONE:1 WITHVA✓REA'CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa birdbale INDIVIDUAL O LOCALAGENCY E:D STATE-AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 111, TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION ri MAILING OR STREET AD DRESS ✓ box b irdicale INDIVIDUAL LOCAL-AGENCY Lj STATE-AGENCY CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY CITY 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 [4T4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindioate 0 1 SELF INSURED 2 GUARANTEE E-3 3 INSURANCE Q A SURETY BOND O 5 LETrER OF CREDIT 6 EXEMPTION 0 gB 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: 1.0 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&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY IT LOCATION CODE -OPTIONAL CENSUS flACTa -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Z . THIS FORM 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 FORMA(SRS) 0 FORD73301417