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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 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 J I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME PHONE It WITH AREA CODE DAYS: NAME (LAST, FIRST) NAME OF OPERATOR NIGHTS: NAME (LAST. FIRST) PHONE It WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ADDRESS PHONE It WITH AREA CODE NEAREST CROSS STREET PARCEL # (OPTIONAL) CITY NAME STATEZIP CODE SITE PHONE WITH AREA CODE CA - ) .# J ✓ BOX E:1 CORPORATION (] INDIVIDUAL D PARTNERSHIP E:j LOCAL -AGENCY O COUNTY -AGENCY' E�:] 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 a 2 DISTRIBUTOR ✓ IF INDIAN # OF TANKS AT SITE 7FA. I. D. # (optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION T OR TRUST LANDS f FMERGFNCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE It WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE It 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 Q INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY = CORPORATION = PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE III TAAIV MA/AICA IAIC110RAATInBI - IRAI ICT RF rnMPl FTEn1 NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY 0 CORPORATION PARTNERSHIP 0 COUNTY -AGENCY a FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Gall (91b) 322-96e9 It questions arise. TY (TK) HQ F4]-4-]-1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE i= 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND E�] 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT = 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: 1. ❑ it. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE MONTHIDAY/YEAR TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNER'S TITLE 1 nr`AI ArFNrV I ISF nNI V COUNTY # JURISDICTION # FACILITY It ❑ F= ❑ LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL Tr I�Irn[] ANATInki AM V THIS FORM MUST BE ACCOMPANIED BY AT LF - (1) UH MUHt NtHMI I Af-rut A I IUN - runm o, ul.Lw� .• • •••• -• •••• • •-•- -• OWNER MUST FILE THIS FORM % rHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUL i ORAGE TANK REGULATIONS FORM A (6-95)