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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W �� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY C SED. SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ( I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 7ERVICE STATIOMI ?nBFRT MCCOMS ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) KETTLEMAN LANE - AVENUE PHONE # WITH AREA CODE CITY NAME STATEZIP CODE SITE PHONE # WITH AREA CODE CA 95240 ✓ BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE 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 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION 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 All - ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME ?M RAFFONI. ETAL CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY 1 7 5 ORANGEWOOD DRIVE Q CORPORATION PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE nnT ; . A III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q 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 4 4- -1 o - 1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND Q 8 STATE FUND b CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND 8 CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT. MECHANISM 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. ❑ It. O III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL KGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # r�-r ❑ LOCATION CODE - OPTIONAL CENSUS TRACT It - 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 ONLY. OWNER MUST FILE THIS FORM WI 'E LOCAL AGENCY IMPLEMENTING THE UNDERGROUNI RAGE TANK REGULATIONS FORM A (6-95)