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66�R C STATE OF CALIFORNIA .! r STATE WATER RESOURCES CONTROL BOARD F 4n�� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,s COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY t NEW PERMIT F_� 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT F__j 6 TEMPORARY SITE CLOSURE F05 -J7 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY 4AME DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NAME OF OPERATOR C NIGHTS: NAME (LAST, FIRST) "' PHONE # WITH AREA CODE ADDRESS Q LOCAL -AGENCY Q STATE-AGENCY 1177 ^ NEAREST CROSS STREET PARCEL # (OPTIONAL) Q COUNTY -AGENCY Q FEDERAL -AGENCY /! STAT ZIPCODE CITY NAME l f�e STATE ZIP CODE ITE PHONE # WITH AREA CODE �D f— CAI/ BOX TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q 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 Q f GAS STATION Q 2 DISTRIBUTORQ IF ✓ IF INDIAN # OF TANKS AT SITE E. P. A. 1. D. # (optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER I OR TRUST LANDS ^ —7 / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAM (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE �r NIGHTS: NAME (LAST, FIRST) "' PHONE # WITH AREA CODE .1 , Zd) -- 63?L Q LOCAL -AGENCY Q STATE-AGENCY 1177 ^ II- PROPERTY OWNER INFORMATION - (MUST 8E COMPLETED) NAME CARE OF ADDRESS INFORMATION CARE OF qDDRESS INFORMATION MAILING OR STREET ADDRESS �� ✓ box to indicate Q INDIVIDUAL MAILING OR STREET ADDRESS ✓ box IDindicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE-AGENCY Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY AM CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY dITYjNA91Ej STAT ZIPCODE PHONE # WITH AREA CODE l f�e 117A/ ?, II�� �—/v _/ `l III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OFF O�WNE& CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS �� ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY �/G CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY AM STA ZIPCODE PPHOO,N�E.# WITH AREA CODE ^7 — �� ff / lLf"� .6Fj / IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4- - 101Z IzI1616 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ boxbindicate 9CI•'f SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND 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 checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. Q II. 7 III. THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # �- 3 LOCATION CODE - OPTIONAL ___]CENSUS TRACT # - OPTIONAL SUPVISOR- DISTRICT CODE • OPTIONAL cz>Z.3.60 3;v THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE WoRMA7�N ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA // FORMA(3193) � � �],� FOR0003A�17