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• 0Vw STATE OF CALIFORNIA .,'^ ``. STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W�� ye cY7 o' Cnbon'un COMPLETE THIS FORM FOR EAC CILITY/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 3 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Ze / %/cam ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 6 v(9 vN «� CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE c CA X CORPORATION INDIVIDUAL PARTNERSHIP 0LOCAL-GENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY TOINgO DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION E::] 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x fcphonap RESERVATION 0 3 FARM O 4 PROCESSOR 0 5 OTHER ORTRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST.FIRST) PHONE Y WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHQNF a II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bob MINIS INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY O FEDEIULAGENCY 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 bin0icau = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEERAL#GENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 3 1 2. Z I L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box w WEau 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 A SURETY SND O S LETTER OF CREDIT 0 6 EXEMPTION O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= II.= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY LOCATION CODE -OPTIONAL CENSUS TR Ts -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL i o3J'p � 3 THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS E OF SITE INFORMATION ONLY, FORM A(5-91) FOR0033A 5