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'aaoua e STATE OF CALIFORNIA �.,, STATE WATER RESOURCES CONTROL BOARD ;a: '1 0 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A mom. �e 0 COMPLETE THIS FORM FOR EACH F ITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER D SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME y� NAME OF OPERATOR S�a 1 ADDRESS ^ NEAREST CROSS STREET I'MCEUIOPTIONAL) CITY NAME 7J` STATE ZIP CODE SITE PHONE 6 WITH AREA CODE CA TOMDCATE D CORPORATION INDIVIDUAL PARTNERSHIP EZLOCALAGENCY COUNTY-AGENCY E�:] STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATIIAN ON A OF TANKS AT SITE E.P.A. I.D.a(oplianaQ O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) _ PHONE A WITH AREA COOP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box khk1kde O INDIVIDUAL E-] LOCAL-AGENCY E:] STATE-AGENCY 0 CORPORATION [::] PARTNERSHIP [:D COUNTY-AGENCY 0 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 tw INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY 0 FEDEMUAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. TY(TK) HQ 4 4 -Ll V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box ainAkate D I SELF-INSURED 0 2 GUARANTEE 31NSURANCE L�]4 SURETY BOND U 5 LETTER OF CREDT =1 6 EXEMPTION 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 APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY r� COUNIY4 lu- JURISDICTION# Y� ( __l L 1 _ LOCATION CODE -OPTIONAL ICENSU T CTA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 9 I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(1291 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOfl0993A-P6