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'.Ou- Ga STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 0 f NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENT ED SITE ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEE TO � 9/+t' C b >✓T14 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME � STATE A ZIP CO E;�� SITE PHONE#WITH AR y,CO ./ BOXCA TO INDICATE PORATION Q INDIVIDUAL Q PARTNERSHIP Q Q COUNTY•AGENCY' Q STATE-AGENCY' Q FEDERALAGENCY' DISTRICTS' If owner of UST is a ublic agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RVATION 0 3 FARM Q 4 PROCESSOR Q 5 OTHER ORT .LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NA?E( AST,FI T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE i NIGHTS: N ST) PHOWE fWITI4 AREA DE NIGHTS: NAME LAST,FIRST) PHONE#WITH AREA CODE I t. ROPERTY OWNER INFORMATION• MUST BE COMPLETED RE OF ADDRESS INFORMATION I I C10 r4+ G G OR STPEET ADDRESS ✓ box b Indicate Q INDIVIDUAL Q LOCAL•AGENCY Q STATE• NCY 6, Tt AIal /J L Q CORPORATION Q PARTNERSHIP Q COUNTY•AGENCY Q FEDERAL-GENCY AME I 9STAT ZIP CODE PHONE#WITH AREA CODE /yIh� V ) -- - Z TANK OW R INFORMATION-(MUST BE COMPLET D) NAME O R CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS – ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY ATE-AGENCY Q PARTNERSHIP Q CO FEDERAL-AGENCY CITY NAME �S�TATEZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - U V. PETROLEUM UST FINANCIAL RESPONSIBILITY'(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box ID indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q S LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo r II is checked. [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.IV II.FI 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 MONTWDAYNEAR I l— ! q -, 3+ LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 1110 1 m 111S LOCATION COD (OPTIONAL CENSUS T AC OP'TIDNAL SUP OR-DIT ICT 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. `\v OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM FORM A(3193) FOR0033A-R7