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STATE OF=FORMA STATE WATER RESOURCES CONTROL BOARD \� �r UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT F1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Ga Z>_4r ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) C-} CITY NAME STATEZ41=70 IP CODE SITE PHONE#WITH AREA CODE l'oo-r- CA 9 �Z.- TOINDI ATE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' [] STATE-AGENCY' 0 FEDERAL-AGENCY' DISTRICTS' If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR RES/ IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 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 CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY `�7-�:; �, �/I�f-�r�1 =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY �Naoc �� a CORPORATION 0 PARTNERSHIP COUNTY-AGENCY E�] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE G-tQ �f 2 / 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 b indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND D 5 LETTEROFCREDIT O 6 EXEMPTION 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. II.0 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3 m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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 oNCY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM FORM A(3193) FOR00"A#17 •