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• • STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE REM F__1 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR DAYS: NAME (LAS , FIRST) PHONE # WITH AREA CODE ADDRESS NEAREST ROSS STREET PARCEL # (OPTIONAL) STJTE� 14V 1'.0 er PHONE #jWITH AREA CODE S CITY NAME STATE ZIP DE SITE PHOqE # WITH AREA CODE ZIP CO E � CA 5J2 I/ BOX TOINDICATE CORPORATION CMJLDIV12M PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 0 FEDERAL -AGENCY' DISTRICTS' It 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 �AS STATION Q 2 DISTRIBUTORO ✓ IF INDIAN # OF TANKS AT SITE E. P. A. 1. D. # (optional) 0 3 FARM 4 PROCESSOR Q 6 OTHER RESERVATION OR TRUST LANDS 13 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRS PHONE # WITH AREA CODE DAYS: NAME (LAS , FIRST) PHONE # WITH AREA CODE MAILING OR TREET ZDAESS � /V ✓ box ID indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY Q CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STJTE� NIGHTS: NAME (LAST, FIRST) -1 PHONE #jWITH AREA CODE S NI TS. NAME (LAST, F ST) '� PHONE # WITH AREA CODE a � SJ z0 d S 0ep ZIP CO E � L 37 - 3 f" II- PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION E MAILING OR TREET ZDAESS � /V ✓ box ID indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY Q CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STJTE� ZIP CODE PHONE #WITH AREA CODE 9' l// a � SJ III. TANK OWNER INFORMATION -(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION E MAILING15R STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY CORPORATION O PARTNERSHIP (] COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME /J c- 14 STATE CA�. ZIP CO E � PH%ONE # WITH%AREA CODE 6d --43i� 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 ✓ boxbindicate 0 1 SELF-INSURED Q 2 GUARANTEE (] 3 INSURANCE Q 4 SURETY BOND D 5 LETTER OF CREDIT 6 EXEMPTION 0 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. Z IL [�] III. 0 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 __7DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY 91D ee 0,Yl q P ,?3ly� 9 ICOUNTY # JURISDICTION # FA �IL � .I LOCATION CODE -OPTIONAL CENSUS TRACT # -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. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (W93) 0 0 FOROM: