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• • % 4 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 4m 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH F ILRY/SITE °'t�•a��"' MARK ONLY t NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE ITEM Q 2 INTERIM PERMIT F-1 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FAC ITY NAME NAME O�TOR LA G ADDRESS NEAREST CR SS STREET PARCEL#(0 NAL) 1 11 CITY NAME STACA P C`O�D�F,� SIS hPH�ONE#WITH ARE`30 ✓ BOX CORPORATION 0 INDIVIDUAL (�PARTNERSHIP Q LOCAL-AGENCY I�COUNTY-AGENCY' F--1 STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS' 9 owner of UST is a public agen , mplete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS I GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) RESERVATION 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS- NAW( ST F RST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE#WIT yy AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMUt/ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRES ✓box to Indicate 0 INDIVIDUAL (] LOCAL-AGENCY ED STATE-AGENCY P, , I:L)e (�CORPORATION PARTNERSHIP (]COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE22 7 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 LOCAL-AGENCY STATE-AGENCY (]CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- -1 1 1 1 ]= V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b indicate I SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND D 5 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 box I or II is ch ed. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O Il. III.El 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 MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE •t7PTlOA14L CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -010770NAL 7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION Ott Y. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A PW) 1/3/f FOR0033A-R7