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STATE OF CAUFORWA :� '0 STATE WATER RESOURCES CONTROL BOARD = UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ':•� 's COMPLETE THIS FORM FOR EACH FACILITY/SITE °��.oe"'- MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPEIUTOfl ADDRESSNEAREST CROSS STREET PARCEl$IOPTDNAL) 11 Per _ z_ CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE CA -77-1-10 T INDICATE0 O CORPORATION l� INDIVIDUAL O PARTNERSHIP 0 LOCALAGENCY EDCWMY#GENCY' I�STATE AGENCY' 0 F®ERAL#OENCY' DISTRICTS' • It owner of UST Is a public agency,corripme the tollowing:name of Supervisor M division.section,or onka which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR q/ IF INDIIAN ON $OF TANKS AT SITE E.P.A. I.D.#(Cphimi 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS �^ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonel DAYS:NAME(LAST.FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PH NE$WITH AREA CODE ),Q SIiKjtjblEItWO NIGHTS: MIME(LAST,FIRST) NERH AREA CODE NIGHFS: NAME(LAS .FIR 7) _ -P N $WITH AREA CODE IV I b If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED V S irs 144 NAME CARE OF ADDRESS INFORMATION 54LLL ©1 MAILING OR STREET ADDRESS '��..p .1boxbinOi O INDIVIDUAL 0 LOCAL-AGENCY D STATEACENCY j BI Q TW_-S Mb 5U /7ICCOORPORATION 0 PARTNERSHIP 0 COUNTY#GENCY 0 FEDERAL#GENU/ CITCoAxS7E-psn Z144 S Z ��WITH AREA CODE r Ills.. TANK OWNER INFORMATION•(MUST BE COMPLETED) l/e (/e NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET A,DD,R,E�S.SI {�/�C Q {J� ✓ box to nicam 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY 13 O I LWL t r W T�l31f ,,b SVIT� C� CORPORATK N O PARTNERSHIP O CWMY#GENGY 0 FEOEIML#GENCY CITY NAME 9RTATE ZIP CODE P ONE i WITH AREA CODE C —(a '"– IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TEMEYHO ® OI OFrffff YHQ 36 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓ Em mi 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND 5 LETTER OF CREDIT D S ExEMPnON O$P OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.IVI III THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S E(P E IG ) OWNER'S TfTLE DATE MON T YrVFA CA)Gl Jv �2 LOCk A C SE ONLY COUNTY• JURISDICTION# FACILITY# AT 7 - mla 3 r P3 ID .7 LOCATION CODE -OP17ONAL CENSUS TRACT$ -OPTIONAL 9l1PVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. l OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) FOR(XCSAf1;