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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 °a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION a 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 N A ^.A t � b� & 4 (ork Ste %I4 P-jr1 dt & I3 - ,3 16 -.� ADDRESS INEAREST CROSS STREET PARCEL # (OPTIONAL) CITY NAME -QAC, STATE ZIP C E X153 SITE PHONE # WITH AREA CODE 0 COUNTY -AGENCY FEDERAL -AGENCY CA STATE 0 - -3 116 ✓ BOX 0 CORPORATION INDIVIDUAL 33 PARTNERSHIP Ej LOCAL -AGENCY 0 COUNTY -AGENCY' STATE -AGENCY' 0 FEDERAL -AGENCY' TO INDICATE DISTRICTS ' I 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 GAS STATION ❑ 2 DISTRIBUTORRE SERVATION # OF TANKS AT SITE E. P. A. I. D. # (optional) 3 FARM Q 4 PROCESSOR Q 5 OTHER I OR TRUST LANDS (� I 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 & 4 (ork Ste %I4 P-jr1 dt & I3 - ,3 16 i 0 ^ � H NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE p� )PA ✓ box to indicate 0 INDIVIDUAL II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i 0 ^ � H MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY w�`��.__. 1%�„�� L• t f!",,, / (] CORPORATION [ PARTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY CITY ''NAAMMEE STATE ZIP�ODF,y PHONE # WITH AREA CODE t _7 = - III TANK nwNFR INFf7RMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION A 1.,..113 A ( (., ti MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL a LOCAL -AGENCY STATE -AGENCY 5-7 �� b CORPORATION 'PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE i PHONE #WITH AREA CODE t _7 = - 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 1 SELF-INSURED = 2 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT = 6 EXEMPTION IJ 7 STATE FUND 0 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND A CERTIFICATE OF DEPOSIT I= 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. ❑ II. ❑" 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 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 INFORMATIUN ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95)