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Pf-!-O'V Ate, S C STATE OF CALIFORNIA .P o STATE WATER RESOURCES CONTROL BOARD v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Ao COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 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 ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE CA ✓ BOX Q CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' I= FEDERAL -AGENCY' TO INDICATE DISTRICTS 0 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 ✓ IF INDIAN I# OF TANKS AT SITE E. P. A. I. D. # (optional) 0 3 FARM 0 4 PROCESSOR 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 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 Q STATE -AGENCY = CORPORATION En 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 Q INDIVIDUAL (] LOCAL -AGENCY a STATE -AGENCY [] CORPORATION PARTNERSHIP 0 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 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate E:] 1 SELF-INSURED 0 2 GUARANTEE Ell 3 INSURANCE 0 4 SURETY BOND [__1 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND O 8 STATE FUND a CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT. MECHANISM = 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. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK 'S ME TE TURF) TANK OWNER'S TITLE DATE MONTHiDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # 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 ONLY. OWNER MUST FILE THIS FORM V IE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNI RAGE TANK REGULATIONS FORM A (6-95)